Chart Talk: Anesthesia Coding Conversations

Another week, another opportunity to learn something new in anesthesia pain management. This week’s spotlight focuses on an unusual but increasingly common technique used for post-operative pain control: fascial plane blocks—with a special focus on the Erector Spinae Plane (ESP) block.

What Is a Fascial Plane Block?

Fascial plane blocks are regional anesthesia techniques where local anesthetic is injected between layers of fascia, rather than directly targeting a single named nerve. The medication spreads along the fascial plane, allowing coverage of multiple nerve branches and dermatomes.

Why the ESP Block Is Considered Unusual

The Erector Spinae Plane (ESP) block is considered unusual because it is performed at a location distant from the spinal cord and major nerve roots, yet it provides broad thoracic or lumbar analgesia. The block is placed deep to the erector spinae muscle, allowing cranio-caudal spread of anesthetic.

Common uses include:

• – Thoracic surgery
• – Rib fractures
• – Breast surgery
• – Abdominal and colorectal procedures
• – Spine surgery

Fascial Plane Block CPT Codes

Fascial plane blocks, including ESP blocks, are reported using the following CPT codes:

Thoracic (ESP) Fascial Plane Block Codes

CPT 64466 – Single injection, (unilateral)

CPT 64467 – Continuous catheter (unilateral)

CPT 64468 – Single injection, (bilateral)

CPT 64469 – Continuous catheter (bilateral)

Lumbar & Sacral (ESP) Fascial Plane Block Code

CPT 64999 – Unlisted Procedure

Documentation Requirements

To support billing for fascial plane blocks, documentation should clearly include:

• – Indication for post-operative pain control
• – Anatomical level(s): thoracic or lumbar
• – Single-shot versus continuous catheter technique
• – Laterality when applicable
• – Separate documentation from the surgical anesthesia record
• – Timing of the block (pre-op, intra-op for post-op pain, or post-op)

Common Audit Pitfalls

A frequent audit issue occurs when documentation simply states ‘ESP block performed’ without specifying the level, technique, or indication for post-operative pain. Incomplete documentation may result in denials or downcoding.

Closing Thoughts

Fascial plane blocks like the ESP block highlight how anesthesia pain management continues to evolve. For coders and auditors, understanding both the clinical intent and the CPT coding requirements is essential to ensure accurate reporting and compliance.

DISCLAIMER:  Chart Talk:  Anesthesia Coding Conversations is intended for educational and informational purposes only. The information presented reflects the sole interpretation and professional opinion of the presenter. It does not represent the views or official guidance of my employer, the Centers for Medicare & Medicaid Services (CMS), the American Medical Association (AMA), or any other regulatory or governing body.

Every reasonable effort has been made to ensure the accuracy of the information provided at the time of publication. However, coding guidelines, regulations, and payer policies are subject to change. It is the responsibility of the reader or participant to verify current guidance and apply professional judgment when making coding and billing decisions.

— Dianne
Chart Talk: Anesthesia Coding Conversations

DISCLAIMER:  Chart Talk:  Anesthesia Coding Conversations is intended for educational and informational purposes only. The information presented reflects the sole interpretation and professional opinion of the presenter. It does not represent the views or official guidance of my employer, the Centers for Medicare & Medicaid Services (CMS), the American Medical Association (AMA), or any other regulatory or governing body.

Every reasonable effort has been made to ensure the accuracy of the information provided at the time of publication. However, coding guidelines, regulations, and payer policies are subject to change. It is the responsibility of the reader or participant to verify current guidance and apply professional judgment when making coding and billing decisions.

— Dianne
Chart Talk: Anesthesia Coding Conversations

Post-operative pain blocks continue to be an area of confusion for many coders, auditors, and providers—particularly when it comes to what is separately reportable, which CPT codes apply, and what documentation is truly required to support billing. This multi-part series is designed to break post-op pain block coding down into clear, practical segments, beginning with a foundational overview of the applicable CPT codes and the documentation elements that must be present to support compliant billing. Each installment will build on the last, addressing common scenarios, compliance pitfalls, and audit-focused considerations to help ensure post-operative pain management services are coded accurately, defensibly, and consistently.

What is required in the documentation in order for the post op block to be billable?

1. Who placed the block? We as coders and auditors cannot assume that the attending Anesthesiologist/CRNA for the anesthesia sedation service also performed the block. The block note documentation must clearly identify the specific provider or who placed the block.  
2. Who requested the block? The documentation for the block should clearly indicate that it was placed at the surgeon’s request. Phrases such as “per surgeon’s request” or “for post-operative pain management, at the request of the surgeon” are commonly used and help establish this. This language is important to support medical necessity in the event of payer questions or audits. Ultimately, the surgeon is responsible for post-operative pain management and must delegate that responsibility when appropriate. 
3. What type of block? Coders and auditors should identify the block type by looking for the specific name of the block performed — for example, interscalene, adductor canal, femoral, intercostal, etc. 
4. What delivery method was used to administer the post-operative pain procedure? The documentation must clearly indicate whether it was a single-shot injection or a continuous catheter technique. CPT selection should be based on the documented method of delivery. 
5. Where was the block placed? Accurate code selection depends on the anatomical location documented in the documentation Specifically, the documentation should clearly identify the nerve or region that was injected, infused, or blocked. For example, a block labeled as “Saphenous” may be reported using CPT 64447 (Femoral nerve block) if performed in the mid-thigh region (Adductor Canal), or CPT 64450 (Other peripheral nerve or branch) if performed below the knee. Additionally, the documentation must specify laterality—whether the block was performed on the left, right, or both sides—to ensure correct coding. 
6. Why was the block placed? Anesthesiologists must clearly document the indication for the block. When a block is performed specifically for post-operative pain and is separately billable as a fee for service, it requires distinct documentation that supports its medical necessity as a separate service. If the documentation is unclear or leaves room for interpretation regarding whether the block was part of the primary anesthetic, coders should query the clinician for clarification to ensure accurate coding and compliance. 
7. When was the block placed? The AMA (American Medical Association) has clarified that anesthesia time can be billed for the period spent placing a block, provided the block placement occurs after induction of the primary anesthetic but before emergence. If the block is placed after anesthesia start time but before induction, discontinuous anesthesia time should be applied, meaning the time spent performing the block is excluded from the total billable anesthesia time. To accurately determine if block time is billable or if discontinuous time must be applied, coder should review the following key documentation elements:   Start time of the block injection/placement of catheter   * Stop time of the block injection/catheter   Induction time (primary anesthetic)  
8. Was the block performed under ultrasound guidance? In 2025, most block codes now include ultrasound guidance, but there are some (64450) that still don’t so it is important to know what type of verbiage we need in order to bill 76942. Ultrasound guidance may be separately billable when it is not included in the description of the nerve block and is adequately supported by documentation. To meet medical necessity requirements, the ultrasound image must be retained in the patient’s permanent medical record and clearly identify the patient and date of service.  The documentation should include language similar to the following examples:  Ultrasound guidance used to guide the needle for satisfactory placement (e.g. “Under US, needle guided and appropriately placed.” “Ultrasound guidance used for needle placement”). Ultrasound guidance used to view medication diffusion (e.g., “US used to visualize spread of anesthetic,” “Medication spread viewed under U/S”). 

Below is a quick overview of different blocks and there CPT Codes. In the Post-Op Block Series, I will be covering different blocks each week.

Disclaimer:
Chart Talk: Anesthesia Coding Conversations is intended for educational and informational purposes only. The content shared does not constitute legal, billing, compliance, or reimbursement advice. Coding, billing, and reimbursement decisions should be based on official sources such as CPT®, ICD-10-CM, ASA guidelines, payer policies, and individual facility policies, as well as the specific documentation in the medical record. Users are encouraged to consult authoritative resources and/or their compliance department for guidance applicable to their organization.