Upper Extremity PNB Part 1

Question 1

T/F: PNBs prolong turnover time

Answer 1

FALSE
PNBs do require some scheduling adjustments, but once you make them, PNBs actually reduce turnover time significantly.

Question 2

T/F: lower extremity PNBs prevent safe ambulation

Answer 2

FALSE

After surgery, a longer acting local anesthetic with a low concentration can continue pain relief with less impact on motor function.

Question 3

T/F A local anesthetic infusion is as effective as a PNB for pain control

Answer 3

False

Independent studies indicate that PNBs are much more effective. PNBs make more theoretical sense because they stop the transmission of the pain signal and prevent the pain cascade from beginning, whereas a local infusion only ameliorates the response after the fact.

Question 4

when can a PNB be reported separately with an anesthesia code

Answer 4

only if the mode of intraoperative anesthesia is general anesthesia, subarachnoid injection, or epidural injection, and the adequacy of the intraoperative anesthesia is not dependent on the peripheral nerve block injection

Question 5

is an epidural or PNB injection administered preoperatively or intraoperatively separately separately reportable for postoperative pain management>

Answer 5

no if the mode of anesthesia for the procedure is monitored anesthesia care, moderate conscious sedation, regional anesthesia by peripheral nerve block, or other type of anesthesia not identified above

Question 6

When an anesthesia provider performs a PNB without a documented request from the surgeon, the insurer may view it as

Answer 6

a self-referral.

Question 7

Performing the block in a procedure room or preoperative holding area rather than the OR helps insurers understand

Answer 7

that this is a separate service from the anesthesia provided for surgery.

Question 8

If blocks must be done in the OR, document the time to perform the block and segregate it from

Answer 8

billable OR time.

Question 9

surgical anesthesia vs post-op analgesia

Answer 9

Question 10

Rather than recording the PNB in the anesthesia record, document it

Answer 10

on a separate piece of paper.

Question 11

T/F: If the block is a primary surgical anesthetic, it is reimbursable as a treatment for post-op pain even if it performs both functions.

Answer 11

FALSE

For example, if you provide MAC during a procedure covered by a nerve block, the block is a key part of surgical anesthesia and cannot be billed as a treatment for post-op pain.

Question 12

The block qualifies for reimbursement as a post-op pain treatment only when

Answer 12

the surgical anesthesia regimen is effective enough to perform the entire procedure without the block (i.e., general or spinal anesthesia).

Question 13

T/F if you use ultrasound guidance, you can bill for this regardless of the block function, in addition to the post-operative pain management billing.

Answer 13

true!

Question 14

-59 CPT modifier vs -26 modifier

Answer 14

The -59 modifier for PNBs performed without ultrasound guidance and the -26 modifier for ultrasound guidance.

Question 15

diagnosis code for acute post op pain

Answer 15

338.18

Question 16

adduction

Answer 16

a motion that pulls a structure or part towards the midline of the body

Question 17

abduction

Answer 17

a motion that pulls a structure or part away from the midline of the body

Question 18

dorsiflexion

Answer 18

flexion of the entire foot superiorly, or upwards

Question 19

plantarflexion

Answer 19

flexion of the entire foot inferiorly, or downwards

Question 20

eversion

Answer 20

the movement of the sole of the foot away from the median plane.

Question 21

inversion

Answer 21

the movement of the sole towards the median plane

Question 22

ultrasound high frequency probe Hz

Answer 22

10 -15 MHz

Question 23

ultrasound high frequency probe is typically

Answer 23

linear

Question 24

high frequency probe depth of penetration

Answer 24

about 4-6 cm

Question 25

high frequency probes are better for

Answer 25

shallow block needing specific tissue differentiation

Question 26

high frequency probes are used for (3)

Answer 26

Popliteal sciatic, interscalene, supraclavicular blocks

Question 27

ultrasound lower frequency probe Hz

Answer 27

2-5 MHz

Question 28

ultrasound lower frequency probes are typically

Answer 28

curvilinear

Question 29

lower frequency probes have a (higher/lower) spatial resolution

Answer 29

lower

Question 30

which probe penetrates deeper than 4-6 cm

Answer 30

Lower Frequency Probes

Question 31

which probe is better for deeper blocks needing less specific differentiation

Answer 31

lower frequency

Question 32

which probe is better for Infaclavicular and lumbar neuraxial

Answer 32

lower frequency probes

Question 33

hyperechoic

Answer 33

brighter ultrasound image relative to surrounding structures

Question 34

hypoechoic

Answer 34

darker ultrasound image relative to surrounding structures

Question 35

anechoic

Answer 35

almost black ultrasound image (reflecting no processed wave

Question 36

echogenic

Answer 36

reflects, or designed to reflect ultrasonic waves

Question 37

how will bone appear on US

Answer 37

“hyperechoic” with a dark shadow “dropout” below.

Question 38

how will fluid appear on US

Answer 38

as a darker “hypoechoic” image.

Question 39

(6) benefits of US guidance

Answer 39

Ability to see nearby vascular structures
Ability to see nerves
Ability to visualize the needle approaching the nerve.
Ability to see local anesthetic spread.
Possibility of reducing complications.
Less painful to use Ultrasound instead of nerve stimulator.

Question 40

ultrasound allows visualization of (3)

Answer 40

the nerves, the important structures, the needle and the injected local.

Question 41

Visualization of the structures during injection of the local means that the needle can

Answer 41

be repositioned if necessary (and most of the time it is beneficial to do this) to ensure that local surrounds the target nerve mass.

Question 42

watching while you inject means

Answer 42

that if you see the local solution accumulating around the nerve, you are reassured that the solution is not going into the vascular space or intrathecally.

Question 43

typical block needle

Answer 43

Typical 22 g insulated block needles can be used.

Alternatively, 18 g Touhy needles sometimes are used.

Question 44

does needle diameter matter in out of plane approach

Answer 44

no, needle diameter would not matter, since the needle is not visualized with this technique.

Question 45

with the in plane approach what diameter can be helpful

Answer 45

a larger diameter needle can be helpful, especially if the nerve is relatively deeper, and a longer needle is required.

Question 46

nerves generally run along….

Answer 46

borders of other structures especially between different muscle groups

Question 47

The characteristic appearance of a peripheral nerve, in ideal ultrasound cross section, looks like…

Answer 47

a bundle of drinking straws viewed end-on (Honeycomb)

Question 48

____________ and ____________ can resemble nerves on ultrasound

Answer 48

tendons and ligaments

Question 49

Peripheral nerves generally run along

Answer 49

spaces between muscles in proximity to vessels.

Question 50

color doppler can be used to detect

Answer 50

flow

Question 51

____________ structures are usually easily distinguished from other targets

Answer 51

vascular

Question 52

the preferred method for following a nerve along its course

Answer 52

transverse scanning by sliding a broad linear transducer

Question 53

plays a major role in optimizing nerve imaging.

Answer 53

transducer manipulation

Question 54

for needle visualization, the needle angle cannot exceed

Answer 54

30º