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Post-Op Pain Management



According to most payers, including Medicare, postoperative pain management is the responsibility of the surgeon and is included in his/her global fee.  However, in some instances the surgeon may request that the anesthesia professional provide the postoperative pain control.  Some commonly seen situations include, but are not limited to: orthopedic procedures on the shoulders, hips and knees and thoracotomies.  So, can an anesthesiologist be separately reimbursed for postoperative pain management procedures in addition to anesthesia care?  What about billing more than one injection?  Is ultrasound guidance separately billable?  The answer to these questions is—absolutely!  If you document your services clearly and follow coding and payer guidelines, receiving reimbursement for your postoperative pain services can be a breeze.

Billing Guidelines:

The most important thing to remember when billing/providing postoperative pain is the “primary purpose” rule.  This rule has been adopted by the AMA and CMS.  Put simply, the rule states that if the postoperative pain procedure’s primary purpose is not to provide anesthesia for the surgery, then it is separately billable.  If the pain procedure, let’s say an epidural for argument’s sake, is part of the anesthesia technique (combined or alone) it is not separately billable.  So, if you have a patient who required regional anesthesia in the form of an epidural, you can’t bill for the placement of an epidural or for the postoperative management of the catheter on the same day as the procedure.   

In some cases more than one nerve block will be required to provide adequate pain coverage.  For example: a patient has a total knee, the anesthesiologist may decide that a femoral nerve block and a sciatic nerve block would better control the pain.  These are billable together; just make sure that each procedure is individually noted and documented clearly in the records.

Sometimes it is necessary to use ultrasound guidance to accurately position the needle for a postoperative pain injection.  This is also billable if you document the use of ultrasound in a brief note and ensure that a permanent image is stored in the medical record.


In most cases a handwritten note on the anesthesia record, describing the procedure and noting that the procedure was performed at the request of the surgeon, is adequate documentation.  The surgeon should also document the medically necessary reason that the patient’s postoperative pain management is being referred to you, per Medicare guidelines (NCCI Ch. II-5, 2013.)  Additionally, if ultrasound guidance is used, a permanent image should be stored in the patient’s medical record and the imaging should be described in the note, specifically mentioning that the nerve to be blocked was visualized under ultrasound guidance.  Be sure to document clearly and thoroughly each postoperative pain procedure that is performed, the time, specific anatomical location and or approach, a brief description of the procedure and the ordering physician’s name.  Clear and thorough documentation can go a long way to ensuring that you are properly reimbursed for your services. 

Payer Guidelines:

As with billing any services related to anesthesia or pain management, knowing your payers’ policies is key to being reimbursed.  Most payers cover post-op pain management in some form or another, but may have specific guidelines for billing.  For example, Medicare stipulates that if a patient receives MAC services for the main procedure, post-operative pain management is not separately billable.  Knowing your payers’ policies can help you obtain the maximum reimbursement for your services.

Though billing for postoperative pain can be tricky, if you document your services thoroughly, follow a few simple guidelines and know your payers’ policies you can bill for postoperative pain management successfully.


NCCI manual.

Heather E. Golfos, CPC, CANPC Coding Department Assistant Manager

On Tuesday, September 17, 2013

Categories: Compliance & Coding News

The information presented herein reflects general information that is current as of the date it was first published. Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.

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