Starting a New Regional Anesthesia Program

Last updated May 9, 2017

banner2Regional anesthesia and acute pain medicine can add significant non-monetary value to a surgical practice in terms of pain relief, reduced incidence of anesthetic- and opioid-related side effects, and faster recovery (1-4). See “Why We Need Acute Pain Medicine Specialists.” However, gaining this expertise requires an investment of time and money, and the reality at the end of the day is that associating economic value to these procedures may increase their utilization. There are no clear guidelines for developing an efficient regional anesthesia and acute pain medicine practice with effective billing strategies in the United States, and the following suggestions are only suggestions based on my experiences setting up programs at two hospitals and are not meant to be prescriptive. Please consult with your practice leadership and billing manager to ensure compliance with billing regulations in your area. Further, actual payment rates will vary between practices due to differences in payor mix.

  • Communication is key.  Before you start implementing changes, meet with your practice leadership and office/department manager to agree on goals. I have found that sitting down with my department’s business, billing, and revenue managers on at least a quarterly basis is highly educational and provides me with frequent feedback on our rapidly-growing practice. Your practice manager can often provide you with the “big picture” – including the overall direction of your institution. For example, a hospital that performs a high volume of orthopaedic surgery may be genuinely interested in a regional anesthesiology and acute pain medicine service to reduce recovery room and hospital stays following surgery (5,6). The potential cost savings that result from a reduction in room and board expenditures may provide value that outweighs minimal revenue generation and may even warrant a stipend from administration to support the practice.  If you utilize a billing service, developing a good relationship with the people involved in sending out your charges is essential. Since they are not directly involved n the provision of healthcare, it is vital to a practice to meet them in person and clearly explain what you do and why you do it. In some cases, when feasible, it is probably worthwhile to have your billing manager observe nerve block procedures and patients’ postsurgical recovery (while preserving patient confidentiality of course). By arming your billing staff with knowledge of your techniques and research, they will be better-equipped to negotiate charges and fair payment with each payor.
  • Identify your customers.  The primary reason for initiating a regional anesthesiology and acute pain medicine program is to benefit patient care. Hospital administrators are also important customers whose support is necessary for a new regional anesthesia program to succeed. As I mentioned, financial support from administration can offset the significant overhead required to start an acute pain service in terms of personnel, equipment, and training expenses. Your administrators may be very interested in improving HCAHPS scores related to pain. We must consider our surgical colleagues are customers as well. Surgeons establish contact with patients during their preoperative visits several weeks to months before surgery. Given this long-term doctor-patient relationship, surgeons that support regional anesthesiology and acute pain medicine can recommend nerve blocks to their patients prior to the day of surgery, leading to higher utilization. Therefore, surgeons’ concerns regarding regional anesthesiology (such as failed blocks, complications, and case delays) must be addressed (7). Finally, your partners in the group anesthesiology practice or department must benefit from implementing an acute pain service. If there will be an initial investment, the benefits that result from this new service should apply broadly to the entire group. The ability to recoup this cost is dependent on the model of regional anesthesiology and acute pain medicine practice implemented, the anticipated volume of procedures, effective billing strategies, and reasonable payment.
  • Cartoon Consistent ProductAssess your resources and develop a system.  There are many different ways to incorporate regional anesthesiology and acute pain medicine into an existing anesthesiology practice (8), and it would be impossible to address each one appropriately in a single article. The goal should be to develop a system that is reliable and consistently available regardless of anesthesiology provider assignment, day of the week, or time of the day. Before you start developing a new regional anesthesiology and acute pain medicine system, some very important questions should be answered ahead of time.  Cartoon 24 hrsWho will perform the procedures?       Depending on the goals of the practice, hiring and/or training staff in specific procedural skills and advanced technology (e.g., surface ultrasound, perineural catheter placement) to develop a core group of skilled personnel is the most important first step. Residency programs have recently created subspecialty regional anesthesiology rotations and there are 1-year clinical fellowships which have led to improvements in training (9,10). Fellowship programs may now apply for accreditation from the Accreditation Council for Graduate Medical Education. For anesthesiologists in practice, appropriate training can be obtained by attending conferences and workshops or learning from partners who have received specialized training.  Where will nerve blocks be performed?  Commonly, regional anesthesia procedures are performed in the operating room before or after surgery. While this may be the only feasible option for physician-only anesthesiology practices, time in the operating room may be better spent. By performing these procedures in an induction area or preoperative holding room (“block room”) while the preceding case is still in the operating room, operating room efficiency can be improved (11). This parallel-processing model may not work for every group practice or institution as it depends on the availability of resources and personnel (12). For anesthesia groups utilizing a care team (anesthesiologists supervising nurse anesthetists or residents), a block room model is recommended.  What do you need? Regional anesthesia procedures require specialized equipment (e.g., nerve stimulators, needles, catheter kits, ultrasound machine) and medications, and centralizing supplies will contribute to effective time management. Storing equipment and supplies in one location, either a block room or at least a regional anesthesia block cart, maximizes efficiency. How do you “make it work” on the day of surgery? Effective time management in a regional anesthesiology and acute pain medicine system is crucial, and advance preparation is essential. Ideally, surgeons begin to discuss postoperative analgesia including regional anesthesia with the patient at the surgical scheduling visit. Alternatively, a preoperative preparation clinic visit or a phone call from the anesthesiologist the day before surgery to discuss specific nerve block techniques can provide patients with early preoperative education to save time and minimize patient anxiety on the day of surgery. You can post educational information for patients online as well – see Regional Anesthesia FAQs. Patients scheduled for surgery amenable to regional anesthesia techniques should be triaged quickly through the admissions process to give the regional anesthesiology and acute pain medicine service adequate time to perform procedures.
  • Design a separate regional anesthesia procedure note.  When nerve blocks are performed for postoperative pain, they are considered separate from intraoperative anesthetic care. Therefore, it is worthwhile to design a distinct procedure note or template for an electronic health record (EHR) to document the details of these procedures, physician referral, and indication for the procedure (pain diagnosis) (13,14). Ideally, a different provider performing the procedure and filling out the paperwork even further separates the nerve block from the intraoperative anesthetic technique, but this is arguably not essential. If the nerve block is used for intraoperative anesthesia, this separate form should not be used to avoid inadvertent double-billing, and the appropriate documentation should be included on the anesthesia record.       When designing new forms, involve your managers to ensure compliance with current policies and regulations.
  • Use appropriate Current Procedural Terminology (CPT) codes and modifiers.  While anesthesia billing services are very familiar with CPT codes, we should not expect them to be able to interpret our procedure notes and deduce the appropriate code. To prevent confusion, we recommend including current CPT codes on our standardized procedure notes or templates. When billing for nerve block procedures performed for postoperative pain management, we also include the modifier -59 to distinguish the block from the intraoperative anesthetic technique (14). This may be important when the same practitioner performs the nerve block and the intraoperative anesthesia. Other pertinent modifiers include -50 (bilateral procedures) and -51 (multiple procedures on the same extremity). Prior to January 2009, the CPT code for continuous nerve blocks included the period of follow-up (10 days). Since January 2009, follow-up for continuous nerve block catheters can be claimed for daily evaluation and management (E&M) using 99231-99233 (based on complexity with 99231 being the lowest) for established in-hospital consults. This series of E&M codes is also recommended for initial in-hospital consults. Daily management of patients with epidural or intrathecal catheters continues to be 01996. When utilizing real-time ultrasound guidance for nerve block procedures, we employ the CPT code 76942. This code for ultrasound-guided needle placement comes from the radiology section of the CPT book. In order to charge appropriately for the use of ultrasound, your documentation should include an interpretation of findings (limited since this is not a diagnostic code) and reason for using ultrasound (e.g., avoiding vascular puncture). Depending on your practice model and availability of EHR, you may choose to print or save an image with your note with a text annotation identifying relative anatomy, needle placement, injection of local anesthetic solution, and avoidance of complications, archive digital images, or save an image to the EHR if possible. The modifier -26 limits the ultrasound charge to professional fee only. Without the professional fee modifier, 76942 includes a technical component charge for equipment storage and maintenance. While we choose to include the -26 modifier when we bill for ultrasound-guided nerve blocks, this decision is practice-specific and should be determined by the providers and managers involved and may depend on the model of practice (e.g., hospital-based vs. office-based).  For updated CMS Outpatient Prospective Payment System coding, please refer to the Outpatient Code Editor quarterly release files.
  • New paravertebral block codes in 2016.
    64461 Paravertebral block (PVB) (paraspinous block), thoracic; single injection site (includes imaging guidance, when performed)
    64462 Paravertebral block (PVB) (paraspinous block), thoracic; second and any additional injection site(s) (includes imaging guidance, when performed) (This is an add on code and must be billed with 64461)
    64463 Paravertebral block (PVB) (paraspinous block), thoracic; continuous infusion by catheter (includes imaging guidance, when performed)

    These replace previously-recommended (15) Category III codes for ultrasound-guided paravertebral facet blocks:  0213T for single-level thoracic (add 0214T for second level and 0215T for third and subsequent levels) and 0216T for single-level lumbar (add 0217T for second level and 0218T for third and subsequent levels).  Category III codes are still in place for ultrasound-guided transforaminal epidural injections.  For cervical/thoracic injections, code 0228T for the first level and 0229T for each additional level.  For lumbar/sacral injections, code 0230T for the first level and 0231T for each additional level.  Do not use 76942 in addition to these codes since ultrasound is already included.  Codes 64479-84 are now limited to epidural injections using fluoroscopy or CT guidance.

  • Transversus abdominis plane (TAP) blocks have their own CPT codes.  In 2015, new codes were released for TAP blocks.  These are not Category III codes.  For unilateral TAP blocks (including rectus sheath and variations), use 64486 for single-injection and 64487 for continuous.  For bilateral TAP blocks (including rectus sheath and variations), use 64488 for single-injection and 64489 for continuous.  These CPT codes include imaging already, so do not add a separate code for ultrasound guidance. For TAP blocks performed for inguinal hernia repair when the ilioinguinal/iliohypogastric nerves are anesthetized, 64425 may be more appropriate; this code does not include imaging or distinguish between unilateral vs. bilateral.
  • Adductor canal blocks and catheters also do not have a specific CPT code listed.  For selective perineural catheter insertions performed distally in the femoral triangle (commonly referred to as “adductor canal” catheters), you may choose to use 64447 (femoral) as this approach has been described as a “selective femoral” (16) nerve block technique.  Anatomically, the common approaches for “adductor canal” blocks describe insertion sites that are located within the femoral triangle (17).  Alternatively, the saphenous nerve block may be coded using 64450 (other peripheral nerve block).
  • ICD-10 officially launched in October 2015.  Diagnosis codes now include laterality when applicable.  For example, pain in right knee is M25.561 while pain in left knee is M25.562.  Acute post-thoracotomy pain is G89.12.  A possibly useful one to remember is “other acute postprocedural pain” G89.18.  Check diagnosis codes carefully, and search when in doubt.

In summary, setting up a new regional anesthesiology and acute pain medicine system takes a hands-on approach but greatly improves surgical programs and patient care.  Meet with your practice manager and billing service early to open lines of communication.  Assess your resources and invest at least as much time in designing your practice model as you will in developing your technical expertise.  Although actual payments will vary between institutions and geographic locations, incorporating regional anesthesiology and acute pain medicine into an anesthesiology practice will add value in addition to controlling costs for the hospital in many ways and providing higher quality recovery for patients.  For more information, read my post about value-based purchasing (“pay-for-performance”) and how this influences acute pain management.

References

  1. Richman JM, Liu SS, Courpas G, Wong R, Rowlingson AJ, McGready J, Cohen SR, Wu CL: Does continuous peripheral nerve block provide superior pain control to opioids? A meta-analysis. Anesth Analg 2006; 102: 248-57
  2. Hadzic A, Williams BA, Karaca PE, Hobeika P, Unis G, Dermksian J, Yufa M, Thys DM, Santos AC: For outpatient rotator cuff surgery, nerve block anesthesia provides superior same-day recovery over general anesthesia. Anesthesiology 2005; 102: 1001-7
  3. Hadzic A, Arliss J, Kerimoglu B, Karaca PE, Yufa M, Claudio RE, Vloka JD, Rosenquist R, Santos AC, Thys DM: A comparison of infraclavicular nerve block versus general anesthesia for hand and wrist day-case surgeries. Anesthesiology 2004; 101: 127-32
  4. Hadzic A, Karaca PE, Hobeika P, Unis G, Dermksian J, Yufa M, Claudio R, Vloka JD, Santos AC, Thys DM: Peripheral nerve blocks result in superior recovery profile compared with general anesthesia in outpatient knee arthroscopy. Anesth Analg 2005; 100: 976-81
  5. Williams BA, Kentor ML, Vogt MT, Vogt WB, Coley KC, Williams JP, Roberts MS, Chelly JE, Harner CD, Fu FH: Economics of nerve block pain management after anterior cruciate ligament reconstruction: potential hospital cost savings via associated postanesthesia care unit bypass and same-day discharge. Anesthesiology 2004; 100: 697-706
  6. Ilfeld BM, Mariano ER, Williams BA, Woodard JN, Macario A: Hospitalization costs of total knee arthroplasty with a continuous femoral nerve block provided only in the hospital versus on an ambulatory basis: a retrospective, case-control, cost-minimization analysis. Reg Anesth Pain Med 2007; 32: 46-54
  7. Oldman M, McCartney CJ, Leung A, Rawson R, Perlas A, Gadsden J, Chan VW: A survey of orthopedic surgeons’ attitudes and knowledge regarding regional anesthesia. Anesth Analg 2004; 98: 1486-90
  8. Mariano ER: Making it work: setting up a regional anesthesia program that provides value. Anesthesiol Clin 2008; 26: 681-92, vi
  9. Richman JM, Stearns JD, Rowlingson AJ, Wu CL, McFarland EG: The introduction of a regional anesthesia rotation: effect on resident education and operating room efficiency. J Clin Anesth 2006; 18: 240-1
  10. Martin G, Lineberger CK, MacLeod DB, El-Moalem HE, Breslin DS, Hardman D, D’Ercole F: A new teaching model for resident training in regional anesthesia. Anesth Analg 2002; 95: 1423-7
  11. Armstrong KP, Cherry RA: Brachial plexus anesthesia compared to general anesthesia when a block room is available. Can J Anaesth 2004; 51: 41-4
  12. Drolet P, Girard M: Regional anesthesia, block room and efficiency: putting things in perspective. Can J Anaesth 2004; 51: 1-5
  13. Gerancher JC, Viscusi ER, Liguori GA, McCartney CJ, Williams BA, Ilfeld BM, Grant SA, Hebl JR, Hadzic A: Development of a standardized peripheral nerve block procedure note form. Reg Anesth Pain Med 2005; 30: 67-71
  14. Greger J, Williams BA: Billing for outpatient regional anesthesia services in the United States. Int Anesthesiol Clin 2005; 43: 33-41
  15. Kim TW, Mariano ER: Updated guide to billing for regional anesthesia (United States). Int Anesthesiol Clin 2011; 49: 84-93
  16. Ishiguro S, Yokochi A, Yoshioka K, Asano N, Deguchi A, Iwasaki Y, Sudo A, Maruyama K.  Technical communication: anatomy and clinical implications of ultrasound-guided selective femoral nerve block.  Anesth Analg. 2012 Dec;115(6):1467-70.
  17. Wong WY, Bjørn S, Strid JM, Børglum J, Bendtsen TF. Defining the Location of the Adductor Canal Using Ultrasound. Reg Anesth Pain Med. 2017 Mar/Apr;42(2):241-245.