Needles, Nerves, and Numbers: A Guide to Ultrasound-Guided Regional Anesthesia (UGRA) Billing in the ED

Katherine Vlasica, DO, FACEP
St Joseph's Health, Paterson, NJ
Beth Kushner, DO, FAAEM
St Joseph's Health, Paterson, NJ

In the fast-paced world of emergency medicine, nerve blocks have become indispensable for providing rapid pain relief to patients with a myriad of conditions, ranging from fractures to acute migraines. However, ensuring proper billing and coding for these procedures is essential amidst the urgency of emergency care. In this article, we present a concise guide tailored to emergency medicine practitioners, focusing on the critical aspects of billing for nerve blocks.

Accurate documentation is a fundamental aspect of healthcare administration, and ensuring that medical services provided are accurately documented and reimbursed helps provide continued care for our patients. For an emergency room (ER) visit, medical billing is divided into two main components: the facility fee and the physician/professional fee. The facility fee covers the costs associated with the use of the hospital's resources, such as laboratory, medical equipment, and support staff. The professional fee, on the other hand, is derived from the work performed by the physician or the physician extenders. This fee is determined by the body of work performed by the provider, which includes tasks such as medical decision making, EKG, X-ray and lab interpretations, procedures, and counseling. The body of work performed during an encounter is translated into CPT (Common Procedural Terminology) codes. Understanding of CPT codes helps to turn physician activities into billable services reimbursed by payers.

When documenting a procedure, it is important to remember components for medicolegal purposes and components for accurate and complete billing. Medicolegal requirements involve a detailed description of the procedure assuring it was performed according to the standard of care, such as pre and post procedure exam, consent, aseptic measures, monitoring, complications. For billing purposes, the note must include several specific elements:

• Indication for the procedure/medical necessity: - Clearly state the medical reason for the procedure. The indication should not be another procedure. For instance, if performing an interscalene block for reducing a shoulder dislocation, note that the indication for the block is “pain uncontrolled by repeated doses of parenteral medications” rather than the reduction procedure itself.  If the indication for the block is “shoulder reduction”, the payment for the block procedure will get bundled into the payment for the shoulder reduction.
• Ultrasound guidance: if applicable, this is billed under CPT code 76942 and requires at least one discoverable image for audit purposes. Note that certain UGRA procedures have ultrasound guidance already bundled into the CPT code and an add-on code is not appropriate. (see table 1)
• Names of nerves anesthetized: Be specific in naming the nerves. For example, when performing a serratus anterior block, instead of saying local anesthetic was placed between the latissimus and serratus to anesthetize the anterior chest wall, specify “thoracic intercostals T2-T10” were anesthetized by placement between the lattisimus and serratus plane at the mid axillary line.
• Resident supervision: Under CMS federal guidelines all resident procedures must be supervised and the procedure note must document attending involvement for reimbursement. This is done in the form of an attestation.
• Medications administered: List all medications with their names and dosages. Note that liposomal bupivacaine is particularly expensive and should be documented accurately for reimbursement purposes.

Table 1 – Common ultrasound guided regional anesthesia procedures in the ED and the associated CPT codes and reimbursement

For blocks that involve perineural injection of an anesthetic agent or steroid around a specific peripheral nerve or branch, and lack a designated CPT code, CPT code 64450 (Injection(s), anesthetic agent(s) and/or steroid; other peripheral nerve or branch) is appropriate.

In recent years, there has been a proliferation of new fascial plane blocks, such as serratus anterior, PENG and erector spinae blocks, which currently lack specific CPT codes.  For blocks where the local anesthetic is deposited into a fascial plane rather than around a specific nerve, CPT code 64999 (Unlisted procedure, nervous system) should be used. For example, when a suprainguinal fascia iliaca is performed, it cannot get coded as a femoral nerve block. While these blocks do not have designated CPT codes, billing them under 64999 does not mean there is no reimbursement. Instead, the payment for these procedures is dependent on the payer and is often reimbursed according to the RVU value closest to a similar procedure, so in the example above, the supraingiunal fascia iliaca would get billed to the payer for 1.34 RVUs.

To ensure proper recognition and reimbursement for their work, EM regionalists should advocate through their professional organizations for the establishment of specific CPT codes for fascial plane blocks. As more awareness and acceptance of new blocks are established, CPT codes can be designated which would help accurately reflect the procedural complexity and improve compensation alignment with the effort and expertise involved. Until such a motion is made, physicians should document the procedures thoroughly to support the billing and facilitate appropriate reimbursement based on the payer's policies.

In the dynamic environment of emergency medicine, mastering the essentials of billing for nerve blocks is imperative for optimizing patient care and ensuring financial viability. By adhering to documentation best practices, selecting appropriate codes, and navigating coverage nuances, emergency physicians can streamline the reimbursement process and uphold the standard of excellence in pain management within the emergency department.