Anesthesia Coding Alert

Review valuable coding updates of 2024 to prepare for 2025.

Whether you’re a novice or expert coder, it can be challenging to keep up with all the coding updates that come out each year. To strengthen your skills, let’s revisit the key takeaways from anesthesia coding this year, so you can hit the ground running in 2025.

Familiarize Yourself With the CABG Code Choices

Coding for anesthesia during coronary artery bypass graft (CABG) procedures can be complex, with factors such as patient age and use of specialized equipment affecting reporting. There are three CPT^® codes for anesthesia during CABG procedures on patients with an atherosclerotic condition: 00562 (Anesthesia for procedures on heart, pericardial sac, and great vessels of chest; with pump oxygenator, age 1 year or older, for all noncoronary bypass procedures … or for re-operation for coronary bypass more than 1 month after original operation), 00566 (Anesthesia for direct coronary artery bypass grafting; without pump oxygenator), and 00567 (Anesthesia for direct coronary artery bypass grafting; with pump oxygenator), each with varying base units.

The codes for grafting of coronary arteries for non-atherosclerotic conditions are 33503 (Repair of anomalous coronary artery from pulmonary artery origin; by graft, without cardiopulmonary bypass) and 33504 (… with cardiopulmonary bypass). The first question to answer when coding anesthesia during CABG is whether a pump oxygenator was used during the procedure. The physician must document “off pump” before you can report the codes with higher base unit values.

See How Anesthesia Service Categories Change Billing

When billing for anesthesia services, it’s crucial to know who supervised the case to assign the correct modifier. Anesthesia claims modifiers are based on four categories defined by the Centers for Medicare & Medicaid Services (CMS): personally performed, teaching, medical direction, and medical supervision. These terms are often misused, so it’s important to understand each classification for accurate reporting.

To qualify as medical direction, the anesthesiologist must:

1. Perform a pre-anesthesia examination and evaluation;
2. Prescribe an anesthesia plan;
3. Personally participate in the most demanding procedures of the anesthesia plan, including induction and emergence;
4. Ensure that a qualified anesthetist performs any procedures in the anesthesia plan that the anesthesiologist does not personally perform;
5. Monitor the course of anesthesia administration at intervals;
6. Remain physically present for all critical portions of the procedure and be available for immediate diagnosis and treatment of emergencies; and
7. Provide post-anesthesia care as indicated.

Your modifier choices to designate when an anesthesiologist medically directed a case are:

• QY (Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist)
• QK (Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals)

Use POPM Pointers to Get Your Claims Paid

A surgeon’s request for postoperative pain management (POPM) could be the deciding factor between receiving payment or receiving a denied claim.

Typically, the surgeon manages POPM, as it’s generally straightforward and included in the surgical fee. However, for complex cases or those needing intensive post-op care, they may seek assistance from the anesthesia team.

“Anesthesia providers are trained in specialty blocks that surgeons are not trained to provide. These blocks and/or catheters allow patients to recover more quickly, saving money in the long run,” says Kelly Dennis, MBA, ACS-AN, CAN-PC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Florida. “Savings result from patients having quicker recovery time, which means less time in the facility, and they require less medication to treat pain,” she adds.

Bottom line: You’ll need documentation from both sides of the care team before your provider can charge for the POPM service.

Determine Professional Charges for Labor and Delivery Using These 4 Methods

In May, we explored labor and delivery anesthesia, noting the lack of formal guidelines for labor epidural billing, which can make reporting these cases particularly difficult. “Accordingly, the RVG [Relative Value Guide^®] lists various options for capturing such time that a provider or group might adopt within their practice,” says Tony Mira, interim CEO and vice chairman of the board of directors at Coronis Health. “The ASA did not mean this list to be exhaustive, but rather representative of some of the more commonly used methodologies acceptable for labor epidural billing,” he notes. They are as follows:

• Capped stick to delivery: Base units associated with the labor epidural code plus time reported in minutes (insertion through delivery), subject to a reasonable cap. Delivery may include related services such as delivery of placenta or episiotomy/laceration repair.

This popular billing method is easy to calculate and helps claims get processed easily. The drawback is that it can be difficult to justify from a compliance standpoint because it doesn’t document face-to-face time with the patient. You also need to negotiate a reasonable cap with the payer and verify whether it has guidelines for billing cases that go beyond labor.

• Anesthesia plus patient contact time: Base units plus 1 unit per hour for neuraxial anesthesia service management plus direct patient contact time (insertion, management of adverse events, delivery, removal).
• Single flat fee for all labor epidurals: You still report the total time for the physician’s involvement but bill the same dollar amount for each epidural instead of billing by time units.
• Incremental time-based fees: (e.g., 0 < 2 hrs., 2-6 hrs., > 6 hrs.)

Filing Clean CRNA Claims Is Easier Than You Think

When billing for Certified Registered Nurse Anesthetists (CRNAs), it’s crucial to understand who employs the CRNA, as most are hospital employees or work for anesthesia groups, with only 18 percent being independent contractors. Understanding state scope of practice laws is also key, as these laws vary in their requirements for physician supervision of a CRNA. As of May 2024, 25 states have opted out, either partially or fully, from the Medicare rule requiring a CRNA to be medically directed or supervised by a physician. It’s recommended to consult the AANA’s State Reimbursement Specialist (SRS) Program and maintain a record of each state’s policy.

Grasping payer payment policies is key. If a CRNA is employed by an anesthesia group, Medicare payments for medically directed and non-medically directed cases are equal. However, billing varies among insurers, and not all accept the same HCPCS Level II modifiers. It’s vital to differentiate between supervision and medical direction for billing. To prevent duplicate claims, consider billing two claims with different charges for the anesthesiologist and CRNA.

Diagnosis Code May not Be Related to the GI Condition

CPT^® distinguishes the anesthesia codes for endoscopic gastrointestinal (GI) procedures as “upper” or “lower,” with the duodenum being the focus of the definition: upper GI procedures are “proximal,” or closer to the duodenum; while lower GI procedures are “distal,” or further away from the duodenum.

This gives you the following choices:

• 00731 (Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum; not otherwise specified)
• 00732 (… endoscopic retrograde cholangiopancreatography (ERCP))
• 00811 (Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; not otherwise specified)
• 00812 (… screening colonoscopy)
• 00813 (Anesthesia for combined upper and lower gastrointestinal endoscopic procedures, endoscope introduced both proximal to and distal to the duodenum)

What Codes Do You Use When a Screening Colonoscopy Turns Diagnostic?

A colonoscopy is deemed a screening when the patient shows no symptoms of polyps or colorectal cancer, regardless of past conditions. If symptoms like abdominal pain or bloody stool are present, the provider should document the need for a diagnostic colonoscopy.

According to CPT^®, you should report anesthesia for a screening colonoscopy with 00812. If the screening becomes diagnostic, use 00811 with modifier PT (Colorectal cancer screening test; converted to diagnostic test or other procedure), as per CMS guidelines. Be mindful of payer policies for screening colonoscopies as they can influence copays, deductibles, and patient costs.

Lindsey Bush, BA, MA, CPC, Development Editor, AAPC