Anesthesia Coding Alert

Watch Your Modifiers With 00160

Surgical codes for endoscopic sinus surgery include CPT 31231-CPT 31294 (various codes for diagnostic or surgical nasal/sinus endoscopy). These codes each cross to anesthesia code CPT 00160 (Anesthesia for procedures on nose and accessory sinuses; not otherwise specified), which is reported as five base units plus time. Only having one anesthesia code may seem like a coding cakewalk, but depending on the surgical codes the surgeon is reporting, your coding can become complicated - especially if the surgeon performs follow-up procedures.

For example, the surgeon may perform a subsequent diagnostic procedure (31231, Nasal endoscopy, diagnostic, unilateral or bilateral [separate procedure]) as a follow-up during the postoperative period. You can code the anesthesiologist's services with modifier -78 (Return to the operating room for a related procedure during the postoperative period) or modifier -79 (Unrelated procedure or service by the same physician during the postoperative period), depending on whether the subsequent procedure is related to the initial procedure.
 
"Being able to include modifiers depends on the documentation," says Samantha Mullins, CPC, an anesthesia coder with the physician group VitalMed Inc., in Birmingham, Ala. "If the patient returns to the operating room (OR) for the treatment of complications related to the sinus surgery (such as cauterization for persistent bleeding after endoscopic sinus surgery), append modifier -78. But report modifier -58 (Staged or related procedure or service by the same physician during the postoperative period) instead if it was noted as a stage or future step in the follow-up process, or if the second procedure is more extensive than the original procedure."
 
Be sure the documentation merits appending modifiers to 00160 before coding follow-up cases because most patients don't return to the OR for a follow-up exam with anesthesia or return for a follow-up diagnostic test. If the physician performs a follow-up diagnostic test, you will likely need to code the test as a separate procedure with a new diagnosis code instead of as a return to surgery.
 
Don't forget to get preauthorization for these types of follow-up procedures. Some carrier policies (such as an older one from Blue Cross/Blue Shield) state that some procedures - such as 31237 (Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement [separate procedure]) - will be denied if you bill them within the 90-day postoperative global period. And if the carrier rejects the surgeon's claim, the carrier doesn't usually pay the anesthesiologist either.

Handle the 'While You're There' Requests

Endoscopic sinus surgery is a long, tedious procedure, partly because of what's involved with the surgery itself and partly because surgeons often perform other procedures during the same session. One common add-on procedure is rhinoplasty (30400-30420 for Rhinoplasty, primary; 30430-30450 for Rhinoplasty, secondary; and 30460-30462 for Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columellar lengthening).
 
Procedures known as "while you're there" requests are common with nasal surgery, Mullins says. "The patient sometimes thinks that because the doctor is already there, he can perform some sort of aesthetic procedure," she says. "This doesn't change the way the physician administers anesthesia, but some things might change from a coding or billing standpoint since you're getting into medically necessary versus cosmetic procedures."
 
Your first step when you learn of an add-on procedure such as rhinoplasty is to explain to the patient that the add-on generates an additional charge. The anesthesiologist usually relies on the surgeon's staff to handle this. "If this isn't explained, it can get sticky," Mullins says. "When did one procedure stop and the other start, so you can allocate the anesthesiologist's time correctly? Did the surgeon's office collect the anesthesia portion of the add-on procedure? Do you bill the surgeon for the additional anesthesia time related to the add-on procedure, or do you bill the patient?"
 
Surgeons sometimes avoid this issue by using the same diagnosis for medically necessary FESS  (such as impaired breathing or sleep apnea) to help justify rhinoplasty or other cosmetic procedures. But if part of the procedure is classified as cosmetic, the carrier will probably deny the anesthesia rendered to perform it. You'll need to bill the patient for that portion of the anesthesiologist's service.
 
Even if only one type of procedure is performed, it may be necessary to perform it in multiple sinuses, says Cindy Parman, CPC, CPC-H, RCC, principal and co-founder of Coding Strategies Inc., in Dallas, Ga. The sinuses are paired, meaning that there is one on the right and left. Surgeons perform some endoscopic procedures unilaterally, but might perform others bilaterally. All CPT procedures are considered unilateral unless stated otherwise (see CPT for more information). Anesthesia coding doesn't change based on unilateral versus bilateral unless the carrier requires surgical codes; simply report the anesthesia code and the associated time units.
 
One of the biggest challenges for many coders is determining the primary sinus surgery code when there may be as many as nine sinus surgery codes on a single case, Parman adds. Although the endoscopic codes all cross to a single anesthesia code (00160), you still want to associate the anesthesia service with the highest base-value surgical code as the primary procedure. To code correctly, you need to know which sinus was treated, what procedure was performed and whether it was diagnostic or therapeutic.

Report Inpatient Cases Correctly

The vast majority of endoscopic sinus surgeries are outpatient procedures. But the surgeon may admit pediatric or geriatric patients or those with complicating medical conditions such as diabetes or heart problems for additional observation or admission following surgery. The physician may admit other patients for postoperative bleeding if the surgeon discovers a malignancy during the surgery or for additional tests.
 
The anesthesiologist may or may not see the patient again once he is admitted to the hospital. Whether you code for the visit depends on the documentation, Mullins says, and where you live.
 
Some states, such as New York, require a postoperative visit or follow-up from the anesthesiologist. If the visit is medically necessary (and not mandatory), you can report subsequent hospital care (99231-99233) with the diagnosis the anesthesiologist is treating. Just remember that the anesthesiologist must be treating a different problem (not treating the diagnosis related to the original sinus surgery) and that the global anesthesia fee includes a routine postoperative visit or follow-up.
 
If the anesthesiologist is simply stopping by to check on the patient but doesn't perform additional services, most coders agree that it's "good customer service" to skip billing for the visit.

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