Anesthetists tout post-op nerve blocks, but who’s going to pay?
Surgeons are slow to accept, but data show reduced length of stay
It’s a technique that offers better pain control, reduced length of stay, and fewer unplanned admissions, according to anesthesiologists and research data. So what’s the controversy with nerve blocks?
"Insurers don’t want to pay for anything new," says Girish P. Joshi, MD, MB, BS, FFARCSI, professor of anesthesiology and pain management at the University of Texas Southwestern Medical Center at Dallas. "The key now is to try to get insurance to realize the importance of it."
Some providers are reporting denial rates that approach 20% to 25%. And sometimes, resistance comes from within the outpatient surgery program. The reimbursement does not cover the drugs or the pump, which is charged separately, says Jennifer R. Greger, MD, with Greater Houston Anesthesia. When providing a block, anesthesiologists cannot bill for the time, she says. Medicare will cover nerve blocks, but the reimbursement rate is about $18 a unit, she says. HMOs’ reimbursement has to do with the contract price, and that amount typically is about $40 a unit in Texas, Greger notes.
With the continuous nerve blocks, there is a cost for the pump ($200 to $300) plus the catheter kit (about $25), says Alan P. Marco, MD, MMM, associate professor and chairman of the department of anesthesiology at the Medical College of Ohio in Toledo.
The cost of a single-injection needle, not including other equipment (such as a nerve stimulator) or drugs, is approximately $15, says Brian A. Williams, MD, MBA, associate professor of anesthesiology at the University of Pittsburgh.
A lot of surgeons don’t understand nerve blocks, Greger says. Surgeons think it will delay their cases, she points out. "Most of the time, that’s not true at all," she says. "It doesn’t delay it because you can get it done ahead of time."
In fact, peripheral blocks have been demonstrated to be more effective and provide better patient-reported outcomes than using strictly opioid-based postoperative analgesia,1-8 Williams says. Nerve blocks can be placed before surgery and coadministered with a total intravenous anesthetic technique (consisting of propofol), he explains. These are associated with lower doses of opioids during and after surgery.
"There’s no unplanned admission for vomiting from narcotics," Greger says.
Patients express a high priority for avoiding nausea and vomiting, Williams notes. "Interviewed patients would spend $48 of $100 allotted to avoid nausea, vomiting, and gagging, and would spend $17 of this $100 to avoid pain.9 I believe that it is time for anesthesiologists to understand these patient preferences to avoid these avoidable side effects, and these preferences should have priority in everyday outpatient practice."
In outpatient surgery, many anesthesia providers give patients volatile gas anesthetics with or without nerve blocks as part of the anesthetic plan, he explains. "Many have been doing this for years, because that is all that was available for years." However, in painful outpatient orthopedic surgery, gas anesthesia has been associated with an unplanned hospital admission as frequently as 17% of cases with no nerve blocks, and in 7% of cases with nerve blocks,10 Williams says.
Gas anesthesia causes nausea and vomiting for about eight hours or so after surgery, he says. Propofol prevents nausea and vomiting for about four to six hours after surgery, Williams adds. "So I block the nerves that are likely to produce pain for more than eight hours despite a routine dose of an anti-inflammatory drug, use propofol exclusively during surgery to render the patient comfortable and/or unresponsive, and after surgery instruct patients to take prescribed opioids as needed for breakthrough pain despite the block, or when the block starts to wear off," he says.
Regional anesthesia patients with propofol can bypass the post-anesthesia care unit (PACU) almost 90% of the time, whereas gas anesthesia patients without block probably will be eligible for PACU bypass less than 10% of the time, if at all, Williams says. With continuous nerve blocks, shoulder surgery patients can go home the same day instead of having to stay overnight for pain control, Joshi says.
And that’s not the only advantage. "There’s a quicker return to activities of daily living," he maintains.
Nerve blocks are not without caveats. For example, some practitioners are uncomfortable sending patients home with nerve blocks because of the risk of injury with an injection, or with continuous nerve blocks, the risk of infection, Marco explains.
Nerve damage is rare, between 0.02% and 0.4%, depending on the study, Williams says.
Also, some providers are concerned that patients could go home with a numb limb, injure it, and not realize it. "There is some risk there," Marco says. "But I think the benefit of better pain control and the benefits of avoiding narcotics and side effects put the balance in favor of nerve blocks."
Other caveats include:
• Practitioners may be resistant.
Nerve blocks are labor-intensive and require an anesthesiologist’s effort perhaps four to five times beyond the time the anesthesiologist would usually spend in immediate proximity of a patient if he or she was medically directing two to four operating rooms, Williams says.
Some surgeons don’t consider their procedures to be painful and may forbid pain management interventions, he adds. Also, the overall process of patient flow from arrival to discharge requires some re-engineering to ensure that the nerve block techniques happen without creating delays in the system, he explains. "Nerve blocks take time, and require additional equipment, disposables, and pharmacy products," says Williams, who adds that nerve stimulators are one required investment. "That doesn’t even account for necessary training, patient education, staff education, and surgeon education."
• Training is important.
Simply attending a one-to-two-day meeting on regional anesthesia techniques does not immediately render one a regionalist, Williams emphasizes. "In order to develop and maintain skills, I believe that regional techniques should be part of routine practice, with perhaps 10 procedures [blocks] per week or so for a practitioner," he says. "If a practitioner is just newly adding block procedures to his/her practice, it may be difficult to meaningfully develop and maintain the necessary skills if one is only performing one to five blocks per month."
Other providers, such as Joshi, say 20-40 procedures a year is enough to be proficient.
It is useful to have a proctor for the first couple of procedures to become familiar with the kits you’re using and small differences in the procedure, such as threading catheters, Marco says.
• Expect resistance from insurers.
Many insurers carve out pharmacy benefits or don’t have it. If the postoperative analgesia regimen is oral narcotics, patients go to a pharmacy and have a prescription filled. But with a nerve block, the physician submits a bill, and insurers must deal with it, Marco points out.
Some providers follow the policy described in the October 2001 issue of CPT Assistant: If these procedures "are performed in conjunction with general anesthesia to provide postoperative analgesia, they are separate and distinct procedures and are reported in addition to the anesthesia code."11
Separate documentation for nerve blocks is critical for payer approval, Greger says. Ensure the surgeon requests postoperative pain management, she says. Include separate progress notes that document what you did, Greger advises. Also, use modifier -59 to indicate that it’s a separately identifiable service, she suggests.
• Stay updated on new research.
Anesthesiologists should do continual reviews of regional anesthesia resources and the current literature, Williams advises.
The review of current literature is important because that will help the practitioner determine which procedures warrant invasive regional anesthesia procedures, and which do not, he says.
"If a complication were to occur on a nerve block patient undergoing a surgical procedure that had not been previously reported with using nerve block analgesia, or a procedure in which nerve blocks had not been shown to be of any particular benefit — e.g., minimally invasive diagnostic knee arthroscopy, then this complication may be difficult to justify or defend after the fact," Williams says. "Caution and proper patient selection are truly essential and important steps."
- Ilfeld BM, Morey TE, Wright TW, et al. Continuous interscalene brachial plexus block for postoperative pain control at home: A randomized, double-blinded, placebo-controlled study. Anesth Analg 2003; 96:1,089-1,095.
- Ilfeld BM, Morey TE, Wang RD, et al. Continuous popliteal sciatic nerve block for postoperative pain control at home: A randomized, double-blinded, placebo-controlled study. Anesthesiology 2002; 97:959-965.
- Borgeat A, Schappi B, Biasca N, et al. Patient-controlled analgesia after major shoulder surgery. Anesthesiology 1997; 87:1,343-1,347.
- Borgeat A, Tewes E, Biasca N, et al. Patient-controlled interscalene analgesia with ropivacaine after major shoulder surgery: PCIA vs. PCA. Br J Anaesth 1998; 81:603-605.
- Borgeat A, Perschak H, Bird P. Patient-controlled interscalene analgesia with ropivacaine 0.2% versus patient-controlled intravenous analgesia after major shoulder surgery: Effects on diaphragmatic and respiratory function. Anesthesiology 2000; 92:102-108.
- Capdevila X, Barthelet Y, Biboulet P, et al. Effects of perioperative analgesic technique on the surgical outcome and duration of rehabilitation after major knee surgery. Anesthesiology 1999; 91:8-15.
- Singelyn FJ, Deyaert M, Joris D, et al. Effects of intravenous patient-controlled analgesia with morphine, continuous epidural analgesia, and continuous three-in-one block on postoperative pain and knee rehabilitation after unilateral total knee arthroplasty. Anesth Analg 1998; 87:88-92.
- Williams BA, Vogt MT, Figallo CM, et al. (S-274) Outcomes after ACL reconstruction: The effect of femoral nerve block analgesia. Anesth Analg — International Anesthesia Research Society 2004 annual meeting abstracts; S-274. Web: www.iars.org/abstracts/abstracts.shtm.
- Macario A, Weinger M, Carney S, et al. Which clinical anesthesia outcomes are important to avoid? The perspective of patients. Anesth Analg 1999; 89:652-658.
- Williams BA, Kentor ML, Vogt MT, et al. The economics of nerve block pain management after anterior cruciate ligament reconstruction: Hospital cost savings via associated PACU bypass and same-day discharge. Anesthesiology 2004; 100:697-706.
- American Medical Association. Anesthesia and postoperative pain management. CPT Assistant 2001; 11:9. Web: www.ama-assn.org/cpt/online.
Source and resources
For more on postoperative nerve blocks, contact:
- Jennifer R. Greger, MD, Greater Houston Anesthesia.
- Girish P. Joshi, MD, MB, BS, FFARCSI, Professor of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center at Dallas. E-mail: email@example.com.
- Brian A. Williams, MD, MBA, University of Pittsburgh Medical Center/South Side Hospital, 2000 Mary St., Suite 341, Pittsburgh, PA 15203.
For more on regional anesthetic techniques, contact:
- New York School of Regional Anesthesia. Web: www.NYSORA.com. Click on "clinical applications" for information including "nerve block techniques for use in outpatients" and "postoperative pain management." Click on "techniques" for information on various regional anesthetic techniques. Click on "what’s new" for a list of scientific meetings and educational text.
For information on peripheral nerve blocks and pain management, go to:
- www.regionalblock.com. The site is maintained by Jacques Chelly, MD, PhD, Professor and Vice Chairman of Clinical Research, Department of Anesthesiology, University of Pittsburgh School of Medicine; and Director of Orthopaedic Anesthesia and Acute Pain Services, University of Pittsburgh Medical Center, Shadyside Hospital.
- uianesthesia.com/rasci/. This web site is provided by the Regional Anesthesia Study Center of Iowa, University of Iowa Health Care, Iowa City. Click on "movies and descriptions of blocks" for movies and discussions of different single-injection and continuous nerve blocks.