Anesthesia Denials Alert: Insights from Recent Cases in WI and CA

Recently, our team was contacted by two different groups, one in Wisconsin, the other in California, for assistance with block denials.  One group was receiving denials from UHC, the other from Medicare.  One group received denials on blocks reported with unlisted code 64999, the other for various established peripheral block CPT codes (64400-64489).  One client had already exhausted all appeals and was tasked with refunding the related revenue back to the payer.  The other is still in the process of appeals. 

In both of the situations, documentation was submitted to support the appeal.  In both situations, the denials were upheld by each respective payer after a review of documentation.  The submitted documentation included the complete record for the patient’s service date, including the block and the surgeon’s documentation.  

The letters received from each payer included the statement cited from NCCI Chapter 2.B.3.4, shared below.  (Note this is only an excerpt, but includes the phrasing included in both denial letters).    

“Postoperative pain management services are generally provided by the surgeon reimbursed under a global payment policy related to the procedure and shall not be reported by the anesthesia practitioner unless separate, medically necessary services are required that cannot be rendered by the surgeon. The surgeon is responsible for documenting in the medical record why care is referred to the anesthesia practitioner.”  

We are recognizing this as a potential issue.  Not knowing where this is going, we have recommended that our clients collaborate with the surgeons requesting any postoperative pain service to ensure there is supporting surgeon documentation for their request and why they are requesting it.  It is unclear if a surgeon’s order will be sufficient, as, to date, our auditors have seen very few surgeon orders that include details stating why the surgeon is requesting the block to be performed by the anesthesia provider.  

This information is shared as a preemptive measure for other clients who have not been impacted.  Please let us know if others have experienced similar situations recently and if we can assist.