Anesthesia Coding Alert

Focus on 2 areas to ensure correct reporting

If your anesthesiologist performs multiple services for a patient on the same day, brush up on some modifier 59 basics to avoid being caught in OIG’s crosshairs.

Verify That Procedures Meet Criteria  

Appending modifier 59 (Distinct procedural service) to your claim means the anesthesiologist performed more than one service for the patient on the same day. But the services you submit with modifier 59 must be “distinct” from each other.

Physicians can perform services qualifying for modifier 59 during the same session or at different times on the same day. Services you can report modifier 59 for include different procedures, sites, incisions, excisions, lesions or injuries, says Cindy Clark, anesthesia coding supervisor with Anesthesiology Consultants in Savannah, Ga.

Your key from a coding perspective is to show that the services were separate from each other before you append modifier 59.

“Records should document separate times that indicate different sessions,” says Joseph Fisher, CPC, anesthesia coding consultant with Per-Se Technologies in Philadelphia. Your provider must clearly document his time with the patient during both services before you can justify modifier 59, especially if the second service is related to the original procedure.

Example: Your anesthesiologist participates in a patient’s coronary artery bypass graft (CABG) procedure (00562, Anesthesia for procedures on heart, pericardial sac, and great vessels of chest; with pump oxygenator; or 00566, Anesthesia for direct coronary artery bypass grafting without pump oxygenator).

The procedure lasts from 9 a.m. until noon. The patient returns to the operating room at 1:10 p.m. for chest exploration due to postoperative hemorrhage (00560, Anesthesia for procedures on heart, pericardial sac, and great vessels of chest; without pump oxygenator).

Appending modifier 59 to the second anesthesia service is appropriate because it indicates that the chest exploration was separate and distinct from the original CABG surgery. Having different start and stop times for each procedure supports your claim that the anesthesiologist performed two distinct services for the patient.
 
Extra help: Fisher recommends sending a copy of each procedure’s anesthesia record when you submit the claims to verify the separate times for each session.

Heads up: Some carriers, such as Empire in New York, allow your physician to use a post-op catheter during the procedure if “such use is only incidental to the general anesthesia. If it is used as the principal method of anesthesia, then it should be included as part of the surgical anesthesia care, and not billed separately.” Train  your physicians to document epidurals thoroughly so you’ll code them correctly--and according to the carrier’s guidelines.

Evaluate Your Post-Op Coding Options

Another common scenario for using modifier 59 is with postoperative pain management, Clark says.

Because physicians can administer either epidurals or nerve blocks for postoperative pain management, Clark’s group has separate documentation for post-op blocks and epidurals. Your coding depends on which treatment modality the physician uses.

Epidural option: Report 62318 (Injection, including catheter placement, continuous infusion or intermittent bolus, not including neurolytic substances, with or without contrast [for either localization or epidurography], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or subarachnoid; cervical or thoracic) or 62319 (… lumbar, sacral [caudal]) for a post-op epidural.

Physicians can use epidurals for postoperative pain management following knee or hip replacement, CABG or lung resection and other extensive procedures. The anesthesiologist can place the epidural before, during or after the primary procedure, but many tend to place it before the procedure and anesthesia time begin.
 
Placing the epidural beforehand is another way to help document that the epidural is separate from the primary procedure’s anesthesia.

Nerve block choices: Report the appropriate choice from 64400-64450 (Injection, anesthetic agent ...) when your physician uses a nerve block for postoperative pain management. He might opt for a nerve block instead of an epidural following carpal tunnel or tendon repair, abdominal, neck or extremity procedures. Nerve blocks are shorter-term in nature, which means they are best performed after the completed procedure.

Appending modifier 59 to the postoperative injection code is acceptable if the physician performed the injection (or placed the epidural) on the same day as surgery, with one caveat: The physician must use the injection or nerve block for postoperative pain relief, not the mode of anesthesia for the surgery. If the anesthesiologist uses the epidural or injection as the mode of anesthesia, you cannot report it separately, with or without modifier 59.

Teach Your Doctors to Document for Success

Reporting modifier 59--especially with post-op pain management cases--hinges on having sufficient documentation to prove your provider performed two distinct services.

“The anesthesia record should clearly document that the general anesthesia during the procedure and the block placement were separate,” Fisher says.

The carriers Clark works with don’t usually request extra documentation for modifier 59 claims, but other carriers might want more information. If your carrier falls in this camp, be sure your providers clearly document the mode of anesthesia (general) in the anesthesia record and note that the block is for “postoperative pain relief.” Including these details should alleviate any confusion for  your carrier.
 
Diagnosis change: As you shift from coding the procedure’s anesthesia to coding for postoperative pain management, change the associated diagnosis.

Instead of reporting the diagnosis as the reason for surgery (which you do with the anesthesia claim), report a diagnosis related to the patient’s pain instead. If the exact procedure matches an ICD-9 code, report V45.xx (Conditions associated with “Other postprocedural states”) and the reason for surgery.

Note: Many carriers accept V45.xx as a primary diagnosis and don’t require a code specifying the pain’s location. If you don’t know the exact location of the pain, submit V45.89 (Other postprocedural status; other) instead.
 
Final documentation note: Documentation should also indicate the surgeon’s request for the anesthesia provider to provide this service because it is included in the surgeon’s service.

Ensure You’re on the Same Page as Carriers

Clark and Fisher agree that many coders have problems when reporting modifier 59, including having carriers that treat modifier 59 the same as modifier 51 (Multiple procedures). That hits your bottom line because carriers reimburse modifier 51 claims at 150 percent instead of paying the full fee for both services.

Other problems include dealing with carriers that don’t reimburse for modifier 59 claims. This stance is a state-by-state issue, so talk with your carrier to verify that you’re following the current guidelines when you submit claims with--or without--modifier 59.

Common Modifier 59 Mistakes

Still more problems with modifier 59 use stem from physician offices. Studies show widespread misuse of modifier 59, so some carriers are beginning to watch its use more closely than before.

Example: Recent data from Empire Medicare and the HHS Office of Inspector General (OIG) yielded an error rate of 49.5 percent with modifier 59. According to the OIG, claims included modifier 59 in an attempt to unbundled NCCI edit pairs, claims reported modifier 59 with an edit’s comprehensive code rather than the component code, and claims mistakenly appended modifier 59 to subsequent codes for repeated services.

The bottom line: You can report modifier 59 for many anesthesia or pain management services if you meet the “distinct and separate” criteria. Pay close attention to when you submit modifier 59, because many carriers pay close attention to its use.