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Anesthesia Coding Alert

Anesthesia on the Move:

Modifier -23 Is Your Key to Payment for Non-OR Procedures

Published on Thu Mar 11, 2004

Underlying conditions can help justify anesthesia use

Whether you code for anesthesiologists at a large or small hospital, chances are you're seeing more charts for services performed outside the operating room. Increase your practice's reimbursement for these "outside-the-norm" services by encouraging underlying diagnosis documentation and using modifier -23 (Unusual anesthesia) when appropriate.

Fight for Your Rights in Radiology Departments

Radiologists perform an ever-expanding list of complex procedures, creating an increased need for anesthesiologists in radiology departments. This is especially true when interventional radiologists perform cardiac catheterizations and other complicated procedures such as transjugular intrahepatic portosystemic shunt (TIPS) placement or intracranial catheter occlusion or embolization.

Anesthesiologists also assist with AAA (abdominal aortic aneurysm) endoscopic repair and some stent placements, says Barbara Johnson, CPC, MPC, in Loma Linda, Calif.

Your group may also provide anesthesia for less invasive radiology procedures because of special circumstances such as the patient's age or physical status. This is especially true for children or handicapped individuals who have low pain thresholds or who have difficulty remaining still during a procedure, such as an MRI or a CT scan.

"I'm seeing that cases are being performed in the imaging/radiology departments in larger numbers for patients who have difficulty being able to lie still, especially smaller children," says Susan West, RHIT, an anesthesia coding consultant with Auditing for Compliance and Education Inc. in Leawood, Kan. When reporting anesthesia during radiology-related procedures, you'll often rely on codes such as 01920 (Anesthesia for cardiac catheterization including coronary angiography and ventriculography [not to include Swan-Ganz catheter]), 01922 (Anesthesia for non-invasive imaging or radiation therapy) and 01926 (Anesthesia for therapeutic interventional radiologic procedures involving the arterial system; intracranial, intracardiac or aortic).

Payment for Diagnostic Tests Can Be Trouble

You shouldn't have trouble collecting anesthesia reimbursement for most interventional radiology procedures, but collecting for diagnostic tests such as electrophysiological studies (EPS), MRI or endoscopies can be a different story. You may have to fight for your reimbursement if carriers question the anesthesia's medical necessity during these procedures.

Johnson recommends two steps to help increase your reimbursement odds. "First, remember modifier -23," she says. "Add this to all cases that would not normally be performed under anesthesia and include any documentation supporting anesthesia's use. If your reason for needing anesthesia is based on a medical diagnosis, also include the appropriate ICD-9 code with codes for the service itself."

Three common medical diagnoses that often support anesthesia use in unusual circumstances are claustrophobia (300.29, Neurotic disorders; phobic disorders; other isolated or simple phobias), cerebral palsy (343.x, Infantile cerebral palsy; or 437.8, Other and ill-defined cerebrovascular disease; other) and Parkinson's disease (332.0, Parkinson's disease; paralysis agitans; or 332.1, Secondary Parkinsonism).

Surgeons should clearly document the need for an anesthesia provider's involvement in these unusual cases, West adds. The physicians should provide the same level of documentation when they perform procedures outside of the operating room that they would in the OR.

Know Your Treatment-Room Codes

Many hospitals now have "treatment rooms" where physicians perform minor procedures. Johnson says some of these services, including the following procedures, can require anesthesia:

  •  Line removal -- 00400 (Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; not otherwise specified) or 00532 (Anesthesia for access to central venous circulation)

  •  Suture removal -- 00400, 00300 (Anesthesia for all procedures on the integumentary system, muscles and nerves of head, neck, and posterior trunk, not otherwise specified) or the appropriate anesthesia code for the specific location

  •  Cast changes or removal -- Code according to the cast site, such as 01130 (Anesthesia for body cast application or revision), 01490 (Anesthesia for lower leg cast application, removal or repair) or 01680 (Anesthesia for shoulder cast application, removal or repair; not otherwise specified).

    These services usually only require anesthesia if the patient can't remain still, Johnson says. Children's centers and orthopedic hospitals use anesthesia for these procedures more often than a small general community hospital would.

    Surgeons now perform line placement (for tunneled or nontunneled catheters) outside the OR more frequently than ever, Johnson says. CPT 2004 revamped line placement codes (36555-36571), allowing more specificity. (See the March 2004 Anesthesia & Pain Management Coding Alert for details on reporting these codes correctly.)

    Expect Non-OR Services More Often

    Due to medical advances and cost-containment measures, physicians now offer anesthesia outside of the OR setting more often than ever before, Johnson says. 

    "ORs are expensive," she says. "If the physician can perform the case in a treatment room instead of the OR, the costs dip considerably. Also, as radiological procedures for vascular and cardio surgery become more advanced, we'll see a big move toward that type of surgery. Anytime the surgeon can repair something without major incisions, then they -- and the patient -- benefit."

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