Anesthesia Coding Alert

Hint: Think administration, not patient state.

While most patient records you code from will note “general” or “MAC” (monitored anesthesia care) for the type of anesthesia used, another term – TIVA – sometimes surfaces. Do you know what TIVA is, or what the acronym stands for? Follow these three steps for a refresher that will keep confusion at bay.

Step 1: Know the Definition

TIVA stands for “total intravenous anesthesia.” Uncertainty among coders arises because TIVA can refer to either MAC or general anesthesia. The term refers to how a drug is administered and means that all anesthetic drugs were given by IV, not inhalation. Drugs given by TIVA can be administered to provide MAC or general anesthesia, depending on the dose concentration and type.

Differentiating MAC from general anesthesia can be tricky for some coders. The American Society of Anesthesiologists’ (ASA’s) “Position on MAC” statement clarifies that, “Monitored anesthesia care is a specific anesthesia service for a diagnostic or therapeutic procedure. Indications for monitored anesthesia care include the nature of the procedure, the patient’s clinical condition and/or the potential need to convert to a general or regional anesthetic.”

Keep up with CMS MAC rules: In the Medicare Claims Processing Manual, CMS states that anesthesiologists should append modifier QS (Monitored anesthesia care service) to report MAC cases. According to the statement, “Monitored anesthesia care involves the intra-operative monitoring by a physician or qualified individual under the medical direction of a physician or of the patient’s vital physiological signs in anticipation of the need for administration of general anesthesia or of the development of adverse physiological patient reaction to the surgical procedure.”

Modifiers G8 (Monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive surgical procedure) or G9 (Monitored anesthesia care for patient who has history of severe cardio-pulmonary condition) might also sometimes be appropriate for MAC claims, depending on the circumstances.

Another point: Remember what the ASA states about MAC, TIVA, and general anesthesia, says Kelly D. Dennis, MBA, ACS-AN, CAN-PC, CHCA, CPMA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Florida: “General anesthesia causes you to lose consciousness.”

Step 2: Get Clarification of the Service

TIVA is a technique, not the type of anesthesia. “Because I’ve heard physicians say that TIVA can apply to either general anesthesia or MAC cases, you must understand the service so you can code correctly,” Dennis advises.

Bottom line: Your anesthesiologist should determine and document whether TIVA is general or MAC.

“Many coders don’t have a clinical background and should not be the one who determines whether the case was MAC or general when the notes indicate TIVA,” Dennis says.

Solution: Talk to the physician or certified registered nurse anesthetist (CRNA) who documents TIVA to determine exactly what they mean by the abbreviation. Be sure everyone in your group uses the abbreviation in the same way and that they note in the patient’s chart if a case moves from MAC or TIVA to general anesthesia.

If you think a case should be coded as MAC, but the provider tells you MAC is incorrect, it could be because they converted the procedure from MAC to general anesthesia.

Step 3: Put Your Knowledge into Practice

Consider this real-world scenario to better understand how TIVA can come into play.

Question: The physician documents TIVA for left L3-4, L4-5, L5-6 transforaminal epidural steroid injections. How should you code it?

Answer: Currently, the base CPT^® code for TIVA for a transforaminal epidural steroid injection (ESI) is 64483 (Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level). Report +64484 (… lumbar or sacral, each additional level (List separately in addition to code for primary procedure)) for additional levels. Remember that both codes include imaging guidance, so you don’t need an additional code for fluoroscopy.

Past history: If you’ve been coding for several years, you might remember reporting TIVA in these situations with 62311 (Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral (caudal)).

Code 62311 was deleted in 2017 and replaced by 62322 (Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance). The correct code now is 64483 since it specifies that the provider administered ESIs.

Also remember that separate anesthesia often is not needed for pain management procedures such as injections. ’Your provider should include documentation of why anesthesia was needed in this situation, such as the patient is a child or has other special considerations.