When Peripheral Nerve Blocks are Considered Medically Necessary and Documentation requirements

Pain management billing includes both general and more difficult procedures that sometimes require a specialist. When billing for pain management you need to know the differences between the following terms:

Chronic pain is a persistent pain during a long term (More than 6 month).

Acute pain begins suddenly and typically doesn’t last less than 6 month).

Diagnostic phase is the identification of the nature and cause.

Therapeutic phase refers to the treatment of the findings in the diagnostic phase.

What do payers look for?

ü  Complete and legible medical notes

ü  Reason for the encounter and relevant history, physical examination, findings, and prior diagnostic test results

ü  The patient’s progress, response to and changes in treatment, and revision of diagnosis should be documented

ü  Assessment, clinical impression, or diagnosis

ü  Medical plan of care

ü  Date and legible identity of the observer.

What do payers want and why?

Health care insurance companies may require reasonable documentation to ensure that a service is consistent with the patient’s insurance coverage and to validate:

ü  That services furnished have been accurately reported.

ü  The medical necessity and appropriateness of the diagnostic and/or therapeutic services provided

Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:

ü  Safe and effective.

ü  Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, that meet the requirements of the Clinical Trials NCD are considered reasonable and necessary).

ü  Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:

Ø  Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient's condition or to improve the function of a malformed body member.

Ø  Furnished in a setting appropriate to the patient's medical needs and condition.

Ø  Ordered and furnished by qualified personnel.

Ø  One that meets, but does not exceed, the patient's medical needs.

Ø  At least as beneficial as an existing and available medically appropriate alternative.

When Peripheral Nerve Blocks are Considered Medically Necessary?

Peripheral nerve blocks will be considered medically reasonable and necessary for conditions such as the following diagnostic and therapeutic purposes:

1. When the patient’s pain appears to be due to a classic mononeuritis but the neuro-diagnostic studies have failed to provide a structural explanation, selective peripheral nerve blockade can usually clarify the situation.

2. When peripheral nerve injuries/entrapment or other extremity trauma leads to complex regional pain syndrome.

3. When selective peripheral nerve blockade is used diagnostically in those cases in which the clinical picture is unclear.

4. When an occipital nerve block is used to confirm the clinical impression of the presence of occipital neuralgia. Chronic headache/occipital neuralgia can result from chronic spasm of the neck muscles as the result of either myofascial syndrome or underlying cervical spinal disease. It may be unilateral or bilateral, constant or intermittent. Nerve injury secondary to a blow to the back of the head or trauma to the nerve from a scalp laceration can also cause this condition. Most commonly it is caused by an entrapment of the occipital nerve in its course from its origin from the C2 nerve root to its entrance into the scalp through the mid portion of the superior nuchal line. Blockage of the occipital nerve can confirm the clinical impression of occipital neuralgia particularly if the clinical picture is not entirely typical. If only temporary relief of symptoms is obtained, neurolysis of the greater occipital nerve may be considered via multiple techniques including radiofrequency, and cryoanalgesia. In addition, the lesser and third occipital nerves can be involved in the pathology of headaches, and can be treated in a similar manner.

5. When the suprascapular nerve block is used to confirm the diagnosis of suspected entrapment of the nerve. Entrapment of the suprascapular nerve as it passes through the suprascapular notch can produce a syndrome of pain within the shoulder with weakness of supraspinatus and infraspinatus muscles. When the history and examination point to the diagnosis, a suprascapular nerve block leading to relief of pain can confirm it. This may be followed by injection of depository steroids that sometime provide lasting relief.

6. When the trigeminal nerve is blocked centrally at the trigeminal ganglion, along one of the three divisions or at one of the many peripheral terminal branches (i.e., supraorbital nerve).

7. Nerve blocks as preemptive analgesia

The signs and symptoms that justify peripheral nerve blocks should be resolved after one to three injections at a specific site. More than three injections per anatomic site (e.g., specific nerve, plexus or branch as defined by the CPT code description) in a six month period may not be medically necessary.

More than two anatomic sites (e.g., specific nerve, plexus or branch as defined by the CPT code description) injected at any one session may not be medically necessary.

If the patient does not achieve progressively sustained relief after receiving two to three repeat peripheral nerve block injections on the same anatomical site, then alternative therapeutic options should be explored.

General Documentation Requirements

ü  Exact Procedure structure

ü  Treatment details (E.g. who administer the treatment and the medication being injected including route, dose, etc…)

ü  If more than one procedure is performed on the same DOS provide a detailed procedure note.

ü  The patient response to the treatment.

ü  If applicable document clearly the use of image guidance (e.g. fluoroscopy, ultrasound, etc…) and include the equipment description.

** Some devices are incidental to the main procedure and not separately billable (e.g. handheld ultrasound devices) **

Specific Documentation Requirements

Assessment of the outcome of this procedure depends on the patient’s responses, therefore documentation should include:

ü  Whether the block was a diagnostic or therapeutic injection

ü  Pre- and post-procedure evaluation of patient

ü  Patient education

When preemptive analgesia is performed by a provider other than the surgeon or the anesthesia professional who provides anesthesia/analgesia for the procedure, there must be a compelling patient care reason for the involvement of the additional provider. The rationale for this approach must be clearly documented in the medical record.

Please Note: In addition to the general documentation rules you must comply with federal and state rules depending on the procedure you are billing.