05/26/2020 – Reporting and capturing revenue for post-operative rounding

Question: How can we capture our work effort and optimize compensation for post-operative pain rounds?

Answer:

  • Post-operative pain rounding defined: a visit by the provider to the patient to assess their current condition. A pain round is not the same as a post anesthesia round. Post anesthesia rounding and the work effort involved is typically captured in the base units reported for the initial primary procedure for which anesthesia services were required.  Circumstance aside, there are times when the anesthesiologist may obtain separate payment for rounds for which the intent is to evaluate the effects of a separately billable postoperative pain procedure.
  • To be considered a compensable patient encounter for which a round will be coded and reported for reimbursement, the following criterion must be met:
    • Timing:  payment will be considered for a round performed the day after the procedure, and subsequent days if applicable.
    • Classification:  There are two distinctly different types of pain rounds, involving different codes, levels of reimbursement, and documentation protocols.
      • Rounding on a patient with an indwelling epidural or subarachnoid continuous drug administration catheter (CPT code 01996).
      • Rounding on a patient without an indwelling epidural or subarachnoid continuous infusion catheter (CPT code 99231).
        • Rounding on a patient with an indwelling peripheral nerve continuous catheter (e.g., femoral nerve catheter) is reported with CPT 99231. Medical necessity is substantiated because the pain medication is infusing at the time of the round.
        • Rounding on a patient who received a Duramorph spinal injection is typically deemed medically necessary as the effects of the narcotic tend to last much longer (CPT 99231).
  • Documentation:  When documenting rounding on a patient with an indwelling epidural or spinal catheter (CPT 01996) there should be specific mention of the catheter and the associated drug delivery system, as well as the following key points:
  • Details regarding the patient’s level of pain and subsequent relief
    • Medication plan
    • Exam of placement site
    • Any side effects
    • Catheter status
    • Provider signature
    • Date of service

When documenting rounding on a patient without an indwelling epidural or spinal catheter, such as a continuous femoral nerve block, continuous sciatic nerve block or post-op Duramorph (CPT 99231), the documentation will be a standard Evaluation and Management note, focusing on patient history, exam and medical decision making.  Recommended key points to include in the formal report are:

  • Review of the medical record
  • Review of diagnostic studies and changes in the patient’s status since the last assessment by the physician
  • Problem-focused interval history and exam
  • Provider signature
  • Date of service

•   Transmitting the Round:  Now that you have done all of the work performing and documenting the round it is vital to ensure that either the electronic report (EMR) or hard copy record reaches the coding department.  Many facilities’ EMR system provides the option to document ancillary services (e.g., rounds, progress notes, anesthesia procedures (i.e., A-line placements)).  Ensuring all relevant documented reports in the facility’s EMR are reaching the coding department is imperative and often requires effective dialogue between IT staff and providers.