Author: Tony Mira
If one considers the historical trend of bundling “standard of care” practices into primary services, can the bundling of acute pain service be far off? What was once a new and increasing revenue stream opportunity may one day become part of the global anesthesia payment.
A review of the history of payment for medical services in the United States reveals a frustrating reality: every time a new service becomes a standard of care, payment is eventually reduced or eliminated. This was true of payment for fluoroscopy in chronic pain where, over the past five years, fluoroscopy has been bundled into the payment for most nerve blocks. We have seen a dramatic growth in the role of anesthesia for endoscopic procedures, the result of which has been new anesthesia codes for endoscopic procedures and a reduction of the base value for lower G.I. procedures. These are just two examples, but the principle can be observed in almost every specialty. It is the law of supply and demand being applied to medicine. As the supply of a particular procedure or service increases, the payment will inevitably drop.
Over the past five years we have seen a dramatic growth in the use of nerve blocks for acute pain management. Today’s question is whether payment for these blocks will eventually be subject to the same erosion.
Past Is Prologue
From a clinical perspective, the literature supports the value of targeted nerve blocks for the management of post-operative pain. Initially, the focus was on the management of pain for orthopedic surgery. The interscalene block for shoulder procedures used to be the most popular procedure because of how painful shoulder surgery could be. Now the adductor canal and popliteal blocks have become some of the most commonly used. It should be noted that these must be billed as femoral and sciatic blocks because of the way the codes were established by the American Medical Association (AMA) in its CPT manual. We are now seeing blocks routinely used for abdominal procedures, which is what led to the creation of the TAP block codes. Many will argue that the routine of use of targeted nerve blocks minimizes the need for opioids in the management of post-operative pain, which is very important given the current opioid crisis.
Over the past five years many client practices have specifically focused on expanding their use of nerve blocks. This has involved identifying clinical opportunities, working with surgeons and training those members not as skilled or comfortable in the administration of nerve blocks. Clearly, the use of ultrasonic guidance (USG) has facilitated this expansion. As one might expect, it is the use of USG—a service that was not routinely billed a number of years ago—that has become the first target of re-evaluation. The documentation guidelines and requirements for USG have been rewritten a number of times in recent years. Now, payers want the provider to document why USG was used to administer the block,as well as that the image was stored. It should come as no surprise that when the four new CPT codes were introduced for TAP blocks (64486, 64487, 64488 and 64489) they included the use of USG. It is bundled into the procedure and is not separately payable. One can only wonder how and when payers will start to question the need for separate payment for the blocks themselves.
Requirements and Roadblocks
Many blocks are now included in the fee schedules for Medicare, Medicaid and all commercial payers. From a billing perspective, coders must confirm that the documentation criteria for these procedures have been met before they can be included in the charge. The clinical documentation must clearly indicate that the block was performed at the request of the surgeon and for purposes of post-operative pain management. (If the block is the primary mode of anesthesia for the surgery, it is not separately payable.) If these necessary criteria are met, does it mean that the billed codes will be consistently paid? Unfortunately, not. There are additional payment rules or roadblocks to payment that may apply. Here are a few:
- Some providers will combine blocks during a given episode of care. When this occurs, the multiple service payment rules apply and payment for the second block is reduced by 50 percent.
- As anesthesia providers refine their block techniques, we are seeing a number of new approaches, some of which do not conform to the CPT descriptors. Perhaps the best example of this is the iPACK block, which has yet to be recognized by CPT as a listed service. This is common with new techniques. They are initially billed with an unlisted code; then, the AMA reviews the volume of these codes over a period of time. Once the volume hits a certain threshold, the AMA will often create a new code within its CPT manual to reflect the new technique or procedure. Until that time, the unlisted code that is used needs to be submitted with documentation. Payers will use individual consideration in deciding whether they will pay for the service. As a result, there is no guarantee of payment for unlisted blocks.
- Some plans in certain states are starting to use a new argument for questioning these charges: medical necessity. It is a classic payer strategy to delay the processing of the claim. A targeted review of a large sample of claims for nerve blocks in one state revealed an increasing number of initial denials and requests for additional information to justify the medical necessity of the service.
- The Covid-19 virus is also having an impact on payment for acute pain blocks, as well as other anesthesia services. Some insurance plans experienced processing delays as they sent staff home to work remotely. More significant, though, has been the impact on patient payments. Unemployment and income reduction have made it difficult for many patients to pay their share of the bill.
The reality is that anesthesia providers do not provide services just because they will get paid for them. Their goal must always be to provide the best anesthetic based on the patient’s expectations and the surgeon’s requirements. The use of targeted nerve blocks for post-operative pain management has become a standard of care. Even if the revenue potential of this service erodes, the clinical justification for it will not. This is just the inevitable reality of today’s medicine.