# Is this separately billable?



## LisaAlonso23 (Mar 31, 2016)

We have an anesthesiologist who wants us to bill separately for an IM injection with meds for pain & post-op nausea. Isn't the administration of meds included in the anesthesia service? Per the NCCI edits I read, this would be unbundling unless I didn't read that correctly. Of course, now I can't find this information. Any help would be appreciated.


----------



## dwaldman (Apr 6, 2016)

Below from the AMA/CPT, it is not intended in a facility setting that a physician would report codes such as 96360-96379. They believe an IM injection would typically be ordered by the physician and provided by the nursing staff. They describe if a separately identifiable EM service was performed then that could potentially be reported, but on the same day as anesthesia service, an EM that does not fall under critical care would not be separately reported/payable.
____________________________________________________________________________________________________________________________
AMA CPT Changes 2012 (can also be found in the AMA CPT manual, Professional Edition)
Physician work related to hydration, injection, and infusion services predominantly involves affirmation of treatment plan and direct supervision of staff.

Codes 96360-96379, 96401, 96402, 96409-96425, 96521-96523 are not intended to be reported by the physician in the facility setting. If a significant, separately identifiable office or other outpatient Evaluation and Management service is performed, the appropriate E/M service (99201-99215, 99241-99245, 99354-99355) should be reported using modifier 25 in addition to 96360-96549. For same day E/M service, a different diagnosis 
________________________________________________________________________________________________________________________

Below it states from the NCCI Policy manual that " 96360-96376 (Drug administration)" is considered an integral service to the anesthesia procedure until the patient is released by the anesthesia ractioner to the care of another physician. 

Anesthesia services include, but are not limited to, preoperative evaluation of the patient, administration of anesthetic, other medications, blood, and fluids, monitoring of physiological parameters, and other supportive services

6. Anesthesia HCPCS/CPT codes include all services integral to the anesthesia procedure such as preparation, monitoring, intra-operative care, and post-operative care until the patient is released by the anesthesia practitioner to the care of another physician.  Examples of integral services include, but are not limited to, the following: 

patient for satisfactory anesthesia induction/surgical procedures. • Placement of external devices including, but not limited to, those for cardiac monitoring, oximetry, capnography, temperature monitoring, EEG, CNS evoked responses (e.g., BSER), Doppler flow. • Placement of peripheral intravenous lines for fluid and medication administration. • Placement of airway (e.g., endotracheal tube, orotracheal tube). • Laryngoscopy (direct or endoscopic) for placement of airway (e.g., endotracheal tube). • Placement of naso-gastric or oro-gastric tube. • Intra-operative interpretation of monitored functions (e.g., blood pressure, heart rate, respirations, oximetry, capnography, temperature, EEG, BSER, Doppler flow, CNS pressure). • Interpretation of laboratory determinations (e.g., arterial blood gases such as pH, pO2, pCO2, bicarbonate, CBC, blood chemistries, lactate) by the anesthesiologist/CRNA. • Nerve stimulation for determination of level of paralysis or localization of nerve(s).  (Codes for EMG 

services are for diagnostic purposes for nerve dysfunction.  To report these codes a complete diagnostic report must be present in the medical record.) • Insertion of urinary bladder catheter. • Blood sample procurement through existing lines or requiring venipuncture or arterial puncture.  The NCCI contains many edits bundling standard preparation, monitoring, and procedural services into anesthesia CPT codes.  Although some of these services may never be reported on the same date of service as an anesthesia service, many of these services could be provided at a separate patient encounter unrelated to the anesthesia service on the same date of service.  Providers may utilize modifier 59 to bypass the edits under these circumstances.  CPT codes describing services that are integral to an anesthesia service include, but are not limited to, the following:  • 31505, 31515, 31527 (Laryngoscopy) (Laryngoscopy codes describe diagnostic or surgical services.) • 31622, 31645, 31646 (Bronchoscopy) • 36000, 36010-36015 (Introduction of needle or catheter) • 36400-36440 (Venipuncture and transfusion) • 62310-62311, 62318-62319 (Epidural or subarachnoid injections of diagnostic or therapeutic substance - bolus, intermittent bolus, or continuous infusion)  CPT codes 62310-62311 and 62318-62319 (Epidural or subarachnoid injections of diagnostic or therapeutic substance - bolus, intermittent bolus, or continuous infusion) may be reported on the date of surgery if performed for postoperative pain management rather than as the means for providing the regional block for the surgical procedure.  If a narcotic or other analgesic is injected postoperatively through the same catheter as the anesthetic agent, CPT codes 62310-62319 should not be reported for postoperative pain management.  An epidural injection for postoperative pain management may be separately reportable with an anesthesia 0XXXX code only if the patient receives a general anesthetic 

Revision Date (Medicare): 1/1/2016 II-9 
and the adequacy of the intraoperative anesthesia is not dependent on the epidural injection.  If an epidural injection is not utilized for operative anesthesia but is utilized for postoperative pain management, modifier 59 may be reported to indicate that the epidural injection was performed for postoperative pain management rather than intraoperative pain management.  Pain management performed by an anesthesia practitioner after the postoperative anesthesia care period terminates may be separately reportable.  However, postoperative pain management by the physician performing a surgical procedure is not separately reportable by that physician.  Postoperative pain management is included in the global surgical package.  Example: A patient has an epidural block with sedation and monitoring for arthroscopic knee surgery.  The anesthesia practitioner reports CPT code 01382 (Anesthesia for diagnostic arthroscopic procedures of knee joint).  The epidural catheter is left in place for postoperative pain management.  The anesthesia practitioner should not also report CPT codes 62311 or 62319 (epidural/subarachnoid injection of diagnostic or therapeutic substance), or 01996 (daily management of epidural) on the date of surgery.  CPT code 01996 may be reported with one unit of service per day on subsequent days until the catheter is removed. On the other hand, if the anesthesia practitioner performed general anesthesia reported as CPT code 01382 and at the request of the operating physician inserted an epidural catheter for treatment of anticipated postoperative pain, the anesthesia practitioner may report CPT code 62319-59 indicating that this is a separate service from the anesthesia service.  In this instance, the service is separately reportable whether the catheter is placed before, during, or after the surgery.  Since treatment of postoperative pain is included in the global surgical package, the operating physician may request the assistance of the anesthesia practitioner if the degree of postoperative pain is expected to exceed the skills and experience of the operating physician to manage it.  If the epidural catheter was placed on a different date than the surgery, modifier 59 would not be necessary.  Effective 


January 1, 2004, daily hospital management of continuous epidural or subarachnoid drug administration performed on the day(s) subsequent to the placement of an epidural or subarachnoid catheter (CPT codes 6231862319) may be reported as CPT code 01996.  • 64400-64530 (Peripheral nerve blocks – bolus injection or continuous infusion) CPT codes 64400-64530 (Peripheral nerve blocks – bolus injection or continuous infusion) may be reported on the date of surgery if performed for postoperative pain management only if the operative anesthesia is general anesthesia, subarachnoid injection, or epidural injection and the adequacy of the intraoperative anesthesia is not dependent on the peripheral nerve block.  Peripheral nerve block codes should not be reported separately on the same date of service as a surgical procedure if used as the primary anesthetic technique or as a supplement to the primary anesthetic technique.  Modifier 59 may be utilized to indicate that a peripheral nerve block injection was performed for postoperative pain management, rather than intraoperative anesthesia, and a procedure note should be included in the medical record.  • 67500 (Retrobulbar injection) • 81000-81015, 82013, 80345, 82270, 82271(Performance and interpretation of laboratory tests) (CPT code 82205 was deleted January 1, 2015 and replaced by CPT code 80345.) • 43753, 43754, 43755 (Esophageal, gastric intubation) • 92511-92520, 92537, 92538(Special otorhinolaryngologic services) • 92950 (Cardiopulmonary resuscitation) • 92953 (Temporary transcutaneous pacemaker) • 92960, 92961 (Cardioversion) • 93000-93010 (Electrocardiography) • 93040-93042 (Electrocardiography) • 93303-93308 (Transthoracic echocardiography when utilized for monitoring purposes)  However, when 


performed for diagnostic purposes with documentation  including a formal report, this service may be considered a significant, separately identifiable, and separately reportable service. • 93312-93317 (Transesophageal echocardiography when utilized for monitoring purposes) However, when performed for diagnostic purposes with documentation including a formal report, this service may be considered a significant, separately identifiable, and separately reportable service. • 93318 (Transesophageal echocardiography for monitoring purposes) • 93355 (Transesophageal echocardiography for guidance for transcatheter intracardiac or great vessel(s) structural intervention(s)) • 93561-93562 (Indicator dilution studies) • 93701 (Thoracic electrical bioimpedance) • 93922-93981 (Extremity or visceral arterial or venous vascular studies) However, when performed diagnostically with a formal report, this service may be considered a significant, separately identifiable, and if medically necessary, a separately reportable service. • 94640(Inhalation/IPPB treatments) • 94002-94004, 94660-94662 (Ventilation management/CPAP services) If these services are performed during a surgical procedure, they are included in the anesthesia service.  These services may be separately reportable if performed by the anesthesia practitioner after postoperative care has been transferred to another physician by the anesthesia practitioner.  Modifier 59 may be reported to indicate that these services are separately reportable.  For example, if an anesthesia practitioner who provided anesthesia for a procedure initiates ventilation management in a post-operative recovery area prior to transfer of care to another physician, CPT codes 94002-94003 should not be reported for this service since it is included in the anesthesia procedure package.  However, if the anesthesia practitioner transfers care to another physician and is called back to initiate ventilation because of a change     
In the patient’s status, the initiation of ventilation may be separately reportable. • 94664 (Inhalations) • 94680-94690, 94770 (Expired gas analysis) • 94760-94762 (Oximetry) • 96360-96376 (Drug administration) • 99201-99499 (Evaluation and management)  This list is not a comprehensive listing of all services included in anesthesia services.


----------



## LisaAlonso23 (Apr 6, 2016)

Thank you! I thought I read it correctly. Sent the exact information to the office manager, yet she is still having co-workers appeal these claims. (The other coder, who is not AAPC-certified, continues to bill this out.) She's claiming that 96372 is a billable code based on our contract, but I don't think she understands that it cannot be billed by an anesthesiologist when anesthesia services are provided. 

I'm finding it to be quite difficult to educate my office when the majority lacks the basic knowledge of the parameters we as coders must work within. 

I appreciate your help.


----------

