Medicare Reimbursement for Nerve Blocks

[BLADEMDA]

The carrier must hold a minimum of three meetings per year and may also work with the CAC through telephone and written communications. Noridian has posted the following schedule of CAC meetings that are open to the public and at which the draft nerve blockade LCD will be discussed:



Alaska 05/09/2013
Arizona 05/28/2013
Idaho 05/22/2013
Montana 05/09/2013
North Dakota 05/14/2013
Oregon 04/13/2013
South Dakota 05/16/2013
Utah 05/02/2013
Washington 04/09/2013
Wyoming 05/02/2013



Reimbursement for the control or management of pain in the immediate postoperative period is bundled into the payment for the procedure, surgical or anesthetic—regardless of the method by which the care provider, including the anesthesiologist, decides to manage pain. Following discharge from the post-anesthesia care unit (PACU), the medically reasonable and necessary placement of regional or peripheral pain blocks or initiation of other new pain interventions or "top-up" dosing may be reimbursable. Providers should not expect separate payment for the establishment of epidural or other pain blocks unless the block is placed following discharge from PACU due to documented inadequate pain control

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[BLADEMDA]

The proposed policy published by Noridian focuses on the timing of the pain intervention: "Providers should not expect separate payment for the establishment of epidural or other pain blocks unless the block is placed following discharge from PACU due to documented inadequate pain control." The CPT and correct coding references listed in the ASA statement make it very clear, however, that it is the purpose of the block or epidural that governs. If the intervention is "employed primarily for postoperative analgesia" it is separately billable and payable (as long as the anesthesia was not "dependent upon the efficacy of the regional anesthetic technique" and the time spent placing the block before induction or after emergence is excluded from reported anesthetic time). Indeed, the CCI Policy Manual, Version 15.3, Chapter is quoted thus:
f the anesthesiologist performed general anesthesia … and reasonably believes that postoperative pain is likely to be sufficient to warrant an epidural catheter, CPT code 62319-59 may be reported indicating that this is a separate service from the anesthesia service. In this instance, the service is separately payable whether the catheter is placed before, during, or after the surgery.
(Emphasis added.) What, then, should one do about the proposed Noridian policy? First, understand its genesis and its place in the hierarchy of Medicare payment policies, and then join in the effort to prevent the finalization of the problem language.

 

[kazuma]

So the future standard of care for CMS thoracotomy patients will be void of preop epidurals and may include a post op epidural when they are writhing in pain on the floor? Awesome. 👎

 

[sevoflurane]

Yeah... I have all the time in the world to bring a patient back to do a block for pain control... especially when we don't have a floater. Extremely inefficient proposal.

This also means higher use of intraoperative narcotics/deeper GA and all their side effects = longer pacu stays, less patient satisfaction and more money expense to the system in the long run.

It also doesn't take into account pre-emptive analgesia.

This is BS.

 

[sevoflurane]

What's next... placing epiduals after vag. delivery?
That makes sense.

People making these proposals just don't get it.

 

[Oggg]

They know that we MDs care for our patients first, so they're counting on us doing preop blocks anyways (without getting paid)

 

[periopdoc]

They know that we MDs care for our patients first, so they're counting on us doing preop blocks anyways (without getting paid)

ding ding ding ding

We have a winner.

- pod

 

[deleted126335]

So the future standard of care for CMS thoracotomy patients will be void of preop epidurals and may include a post op epidural when they are writhing in pain on the floor? Awesome. 👎

Nope. Standard of care is the same. Getting paid, requires the patient first writhing in pain on the floor.

 

[urge]

The block/GA combination for ortho got abused too much.

Thoracic cases should be an exception, but you guys ruined it for those patients. When the pendulum swings, it swings too far in the other direction.

 

[excalibur]

Isn't uncontrolled pain a reason not to discharge someone from PACU?

But you won't get reimbursed if you block a patient who is in terrible pain in PACU...only if he is out of PACU.

I can see it now. "Discharge the patient to the block room and call me when he's there"..

 

[robberbaronista]

Blade- Just want to say thanks. Without folks like you out there keeping us apprised of the goings on we would be even further up s+it creek than we are now. Keep an eye open guys, do not take this kind of crap for granted. With the meat cleaver coming full force towards physician reimbursement (because we are the only spending area politicians can apparently figure out how to control), we must fight for our fiscal lives at every opportunity. The fact that meeting places and times are already posted makes the rest of our jobs that much easier.
Kudos BLADE

 

[deleted126335]

The block/GA combination for ortho got abused too much.

Thoracic cases should be an exception, but you guys ruined it for those patients. When the pendulum swings, it swings too far in the other direction.

Abused? Shouldn't every TKA, every ACL, every major shoulder, major foot surgery get a block?

I know that's what I'd want. Is that what you call "abuse"?

 

[Random Anesthesiologist]

Isn't uncontrolled pain a reason not to discharge someone from PACU?

But you won't get reimbursed if you block a patient who is in terrible pain in PACU...only if he is out of PACU.

I can see it now. "Discharge the patient to the block room and call me when he's there"..

So yeah, now you have to discharge them from PACU and wait for them to complain of intolerable pain (or some similar descriptor)?

I fail to see how this is an improvement to healthcare :/ (facetious, I know it's about the $$)

 

[Random Anesthesiologist]

Abused? Shouldn't every TKA, every ACL, every major shoulder, major foot surgery get a block?

I know that's what I'd want. Is that what you call "abuse"?

Just went to a seminar a couple months ago by a local ortho with excellent post-op recovery for TKAs and such based on pts being able to start ambulating with PT the afternoon/evening of their surgery due to excellent pain control, which includes blocks.

 

[urge]

Abused? Shouldn't every TKA, every ACL, every major shoulder, major foot surgery get a block?

I know that's what I'd want. Is that what you call "abuse"?

How come you are not addressing the other part of the block/GA combo?

You don't need GA for any of these.

 

[dA pilot]

How come you are not addressing the other part of the block/GA combo?

You don't need GA for any of these.

I equate a spinal to a GA as a primary anesthetic. If you are doing TKA's and ACL's completely under PNB then all the power to you. I fully admit that my pnb's do not provide enough surgical anethesia for these cases, especially with a tourniquet.

I can understand the perception of abuse of doing an AV fistula under a supraclavicular block with propofol sedation and billing the block as post op analgesia.

 

[deleted126335]

I equate a spinal to a GA as a primary anesthetic. If you are doing TKA's and ACL's completely under PNB then all the power to you. I fully admit that my pnb's do not provide enough surgical anethesia for these cases, especially with a tourniquet.

I can understand the perception of abuse of doing an AV fistula under a supraclavicular block with propofol sedation and billing the block as post op analgesia.

👍

 

[Scumlee13]

How come you are not addressing the other part of the block/GA combo?

You don't need GA for any of these.

You don't need GA for a shoulder reconstruction after an interscalene block? Even though the patient is in lateral decubitus? Field avoidance? Forearm draped vertically over a board? 2-3hrs? So you then provide GA level-sedation with no airway?

 

[Oggg]

I can understand the perception of abuse of doing an AV fistula under a supraclavicular block with propofol sedation and billing the block as post op analgesia.

Doing a block for an AV fistula requires more work but ideally avoids GA or heavy MAC. But since they wont pay us for this extra work, we run a PPF drip so we can bill for postop pain. The abuse started with them