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5 TIPS FOR PROPER DOCUMENTATION AND BILLING OF POST-OP PAIN BLOCKS

By Renee TomcaninBecker’s ASC Review

5 TIPS FOR PROPER DOCUMENTATION AND BILLINGOF POST-OP PAIN BLOCKS

Many orthopedics procedures, especially shoulder and knee surgeries, often require a pain block to manage the patients’ pain postoperatively. However, these claims are some of the most commonly denied in ASCs on the first pass, often due to payor issues or confusion on the front-end.

Bill Gilbert, vice president of marketing, and Brice Voithofer, vice president of ASC and anesthesia services, for AdvantEdge Healthcare Solutions, discuss five tips for successful billing and docu-mentation of post-operative pain block procedures.

1. POST-OP PAIN BLOCK SHOULD BE CLEARLY SEPARATED FOR INSURANCE COMPANIES. blocks typically require two providers, the surgeon and the anesthesiologist, to document how the patient was treated. Often, they will use the same document to record the anesthesia event as well as the post-op pain block (POP), and the insurance company will usually deny the claim the first time around. Mr. Voithofer says this is typically because the payor is unsure if the correct steps were met to justify the POP.

“A second form is good practice to clearly separate the post-op block from the anesthesia delivery used for the surgical procedure itself. Insurers will need to see a surgeon’s request and a second reason for why this block was performed,” he says.

Mr. Voithofer further suggests having the block performed in a separate room from where the patient received anesthesia prior to surgery to further indicate a clear distinction between the post-op block and the anesthesia used in surgery. “It doesn’t have to be a specific block room, just a separate area from where the patient previously received anesthesia,” he says.

Mr. Gilbert adds that having a separate form reduces the chance of insurers thinking the block is part of the operative report. “It is very easy for these two to be blurred, so anything that can be done to delineate the two is important,” he says.

AT A GLANCE:

1. Use a separate form (claim)

2. Surgeon’s report must document

the request

3. Anesthesiologist should document

clinical aspects and reason

4. Ultrasound-guidance needs

careful documentation

5. No “assumptive” coding by

staff

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5 TIPS FOR PROPER DOCUMENTATION AND BILLINGOF POST-OP PAIN BLOCKS

ahsrcm.com | 908-279-8120

2. MAKE SURE THE SURGEON’S REPORT DOCUMENTS THE REQUEST FOR THE POST-OP BLOCK. The surgeon needs to record the actual request for a post-op pain block in the operating notes, according to Mr. Voithofer. “Many surgeons will say that they (or the patient) requested the block during the procedure, but it is not documented. If the request is already in the patient file, it makes it easier to receive payment the first time,” he says.

Mr. Voithofer notes that if the request is not included in the patient file, it can often be appealed; however, an appeal will prevent payment in a timely manner.

If an ASC is not using a second report for the post-op pain block, the surgeon should place the operating report in the patient file immediately so the anesthesiologist can notate on the report.

3. THE ANESTHESIOLOGIST SHOULD INCLUDE CLINICAL ASPECTS AS WELL AS THE REASON FOR THE BLOCK.Mr. Voithofer says anesthesiologists should include clinical aspects of the block on their reports

including time, drugs used, needle position, needle depth, location, etc. The anesthesiologist

should also include the reason the surgeon requested the block. “Many centers have checklists

for reasons why a block may be requested right on the operating report. This will help document

if and when a surgeon requests something out of the norm,” he says.

4. ULTRASOUND-GUIDED NEEDLE PLACEMENT REQUIRES ADDITIONAL DOCUMENTATION.Ultrasound-guided needle placement should also be carefully documented, according to Mr.

Voithofer. “We performed a recent analysis at a center that used ultrasound and found the center

was not printing out the images with annotations, which resulted in either delayed or outright

denial of the claim,” he says. “Centers should train anesthesiologists on what is required, such

as a print out in addition to dictation, so that the anesthesia group and the ASC are both mindful

of what is needed for reimbursement. Ultrasounds are not cheap, so it is better to send complete

reports before billing.”

5. BILLING STAFF SHOULD BE TRAINED NOT TO “ASSUMPTIVE CODE.”” An ASC’s billing and coding team should be knowledgeable enough to understand what is needed

in a complete report before sending it off to the payor, Mr. Voithofer says. With regard to post-op

5 TIPS FOR PROPER DOCUMENTATION AND BILLINGOF POST-OP PAIN BLOCKS

ahsrcm.com | 908-279-8120

pain blocks, billers should not immediately assume that all of the documents are complete. He

says, “Assumptive coding can be as bad as up-coding. Just because a post-op request exists, it

does not mean that the request is in the operative report.”

Mr. Gilbert says that centers should take the time to ensure that their entire billing staff is aware

of what is needed for post-op blocks since failure to properly document and bill can represent not

only a reimbursement issue, but a compliance one as well. “If your center is doing a lot of these

procedures, you should have a plan for how you handle them and a discussion to review the basics

of documenting the procedure. There have been some recent changes, and you shouldn’t assume

that everyone is complying with the new requirements, so it is important to check and make sure

everyone is on the same page,” he says.

Learn more about AdvantEdge Healthcare Solutions.