Surgeon order for post-op pain blocks

[Dr.whom]

When you guys do pain blocks and epidurals for post-op pain control, do you require written order by the surgeon?

We had a billings auditor look at our records and they say that we need written order for the blocks in order to properly bill for it.

The problem is trying to get all our surgeons to consistently write orders for the blocks. It gets to be a hassle to keep reminding them and asking them for each case.

We used to just do blocks for cases that generally justify a block as long as the patient wants it. Is it reasonable and justifiable to just do that? I feel the auditing company we hired to look at our billing practice may be too conservative in their assessment.

How do you guys handle this in your practice?

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[chocomorsel]

I love how surgeons have to give us orders to do our job. What a bunch of crap.

 

[Man o War]

Do you have EMR so you can prepopulate it on a standard order set for each surgeon?

 

[Dr.whom]

We have emr, but surgeons dont put orders in it until after surgery. Their surgical orders are still on paper.

 

[ZzzPlz]

We had that issue, but only with BC/BS. They tried to do a shake down and not pay for blocks since no surgeon ordered it. Total BS, but you gotta play the game I guess.

Our surgeons all use standard order sets—just talk to them and have them add “anesthesia to perform nerve block for post op pain” to their order set. Problem solved.

Another option for surgeons who don’t use order sets or are new/visiting is to have the PACU nurse put a nursing communication order in for a nerve block.

Are you getting this problem just from blue cross or other carriers too?

 

[Dr.whom]

We haven't really had a problem with the insurance companies.

This issue was pointed out to us by an auditor we hired to make sure our billing practice is kosher.

This same auditor told us that to bill for a running labor epidural, we need to physically check on the patient every few hours. We thought this was BS since we are in house 24/7 and are always a few minutes away with a phone call.

 

[NICMAN]

I think the technical issue is that another physician needs to consult you for post op pain management.

Just have them put an order in that says "Acute Pain Consult". You can't technically refer yourself for acute pain management for procedures--conflict of interest. I know it is BS but some Ophthalmologist have to have optometry refer patients to them for cataracts in some states.

As far as labor epidurals, I think that if you are billing for time then the standard is every 3 hours. That ain't going to happen between 12 and 6AM in most cases but that is the technical standard I think.

 

[deleted162650]

We haven't really had a problem with the insurance companies.

This issue was pointed out to us by an auditor we hired to make sure our billing practice is kosher.

This same auditor told us that to bill for a running labor epidural, we need to physically check on the patient every few hours. We thought this was BS since we are in house 24/7 and are always a few minutes away with a phone call.

That auditor is a monkey. No carrier (private or government) requires vitals during a running epidural - at least in my state anyways.

We don't need an order from the surgeon for a block. We do have "Nerve block at request of surgeon/patient" built into our block documentation though.

Even so, it would be a consult request - not an order. Again, fire your auditor. If the insurance companies aren't pushing back, then I'm not sure why this clown thinks it's an issue. This isn't the first instance I've heard of an "auditor" that doesn't know their ass from their elbow. Maybe "auditing" is this guys side gig - his day job is with JCAHO.

 

[pgg]

This same auditor told us that to bill for a running labor epidural, we need to physically check on the patient every few hours. We thought this was BS since we are in house 24/7 and are always a few minutes away with a phone call.

When I was a resident I rotated at a prominent OB hospital where the policy was a written note on all labor epidurals every 90 minutes. They claimed it was a billing requirement.

 

[B-Bone]

The labor epidural billing can be done two different ways. If you bill for time while it's running, you have to document VS and pain scores every hour, I believe. I think you get an additional unit per hour for this. This is how we did it at my residency program where residents did this. In private practice, we just bill for the base units plus time units for "facetime" (when you are actually in the room placing the catheter or rebolusing or replacing).

As far as the nerve blocks, we were also advised by an auditor to get some documentation of request by the surgeon. We elected not to go with an order from them (because we didn't want to be depending on the surgeons for documentation of something that could get us a regulatory or insurance "ding"). Instead, we write a note in the EMR that requires their cosignature. The language was drafted by our billing company along with our retained auditor:

"*** was requested by Dr. *** for postoperative pain control, within the expertise of an anesthesiologist who is uniquely trained and qualified to perform the procedure."

 

[deleted162650]

The labor epidural billing can be done two different ways.

True. You can either bill a flat fee, or you can bill base units + time. A labor epidural pays at 1 unit/hr instead of 4 like a normal surgical case, but you can have an unlimited number of epidurals running simultaneously. Regardless of which way you bill, there is no requirement to document vitals at any frequency while it's running.

 

[d9sccr]

The nerve block thing requiring an order seems silly for the insurance companies to push back against. If they required that, could you not bill for both a consult and then a procedure?