Billing for Post-Operative Pain Blocks

By: Hal Nelson, CANPC
Vice President, Anesthesiology Services
MSN Healthcare Solutions

Post-operative analgesia managed by Anesthesiologists has become the standard of care for many of today’s surgical procedures. This article is intended to provide guidance on the documentation and billing requirements for such services.

National Correct Coding Initiative

To better understand the background on this issue, we must first look to the National Correct Coding Initiative (NCCI). The NCCI was developed by Medicare in the mid-1990s, to help prevent the improper payment of procedures that should not be billed together. When it comes to anesthesia and pain blocks, NCCI offers the following guidance:

Postoperative pain management services are generally provided by the surgeon who is 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 to document in the medical record the reason care is being referred to the anesthesia practitioner.

Post-Operative Analgesia

It is important to note the timing of when this regulation was originally promulgated, along with the fact that it is still in place. 25 years ago, post-operative analgesia was typically managed by surgeons in the form of intravenous patient controlled analgesia (IV PCA), without the involvement of Anesthesiologists.

Since there was no pain transfer of care, the regulation was essentially meaningless. However, clinical advances (such as targeted nerve blocks and ultrasound guidance) well suited to Anesthesiologists’ skillsets would eventually lead to anesthesia departments assuming this important aspect of patient care.

Post-Operative Pain Management Documentation Requirements

In the end, a regulation that was once dormant is now one that anesthesia practices should pay close attention to. Compliance with NCCI guidelines presents a real challenge for many groups, who have no control over the surgeon’s charting practices. Electronic Medical Records (EMRs) have helped greatly in this regard, with one-click surgeon macros offering a simple and seamless solution to documentation requirements (sample verbiage below).

Clinical practice locations not yet on EMRs have developed similar surgical order sets, or have attested to the transfer of care within their own anesthesia record and/or block note. Although the latter attestation approach is not ideal, it has not been challenged (to date) by insurance carriers and represents a “minimum necessary” approach.

Sample Documentation Verbiage:

Surgical Transfer of Care: Pain Management requiring expertise of Anesthesiologist. Nerve block placed primarily for post-op pain management, at surgeon’s request. 


Like many Medicare payment policies, commercial insurance plans have adopted similar coverage guidelines for post-op analgesia. With pain blocks representing a significant portion of an anesthesia practice’s revenue stream, it is important to confirm that documentation is sufficient to support payment for these services.

As mentioned in previous MSN educational articles, pain blocks cannot be billed separately with MAC anesthetics, nor can they be billed when documented as being part of the primary mode of anesthesia.

Hal Nelson, Vice President Anesthesiology Services


VP of Anesthesiology Services

Hal has 30+ years of experience on both the payor and RCM side, with a focus in Anesthesia. He formerly worked as a senior claims approver at United Healthcare, as well as a compliance officer for multiple national anesthesia billing companies. His broad-based experience ensures that MSN clients have a resource for documentation and billing issues. His past speaking engagements include ASA, MGMA, Dartmouth, and Johns Hopkins.

This educational guide was prepared as a tool to provide education for documentation and coding. It is not intended to affect clinical treatment patterns. The material provided is for informational purposes only. Efforts have been made to ensure the information within this document was accurate on the date of distribution. Reimbursement policies vary from insurer to insurer and the policies of the same payer may vary within different U.S. regions. All policies should be verified to ensure compliance. CPT® codes, descriptions and other data are copyright of the American Medical Association (or such other date of publication of CPT®).All Rights Reserved. CPT® is a registered trademark of the American Medical Association. Proprietary and confidential document.  All rights reserved. No part of this document may be reproduced or used in any manner without the written permission of MSN Healthcare Solutions, LLC.

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