Anesthesia Coding Alert

The latest Correct Coding Initiative (CCI) edits delete previous CCI edits for many acute postoperative pain management codes, and change modifier indicators for some of the most common pain management  rocedures. CCI 15.3 went into effect Oct. 1 andincludes thousands of new, swapped, and terminated code pairs you need to implement now in order to file the correct codes and get reimbursed accordingly.

"The big changes for anesthesia and pain management involve the change from a '0' modifier indicator to a '1' modifier indicator," says Marvel J. Hammer, RN, CPC,CCS-P, PCS, ACS-PM, CHCO, owner of MJH  Consulting in Denver. Having a "1" modifier indicator means you can append a modifier and bypass the bundling edits, thus gaining clearance to report both procedures.

Example: CCI 15.3 lists trigger point injections 20552 (Injection[s]; single or multiple trigger point[s], 1 or 2 muscle[s]) and 20553 (... single or multiple trigger point[s], 3 or more muscle[s]) as Column 1 codes. Now you can append modifiers to bypass the edits for trigger point injections and Column 2 codes representing some of your most common procedures:

• 62310 -- Injection, single (not via indwelling catheter), not including neurolytic substances, with or without contrast (for either localization or epidurography), ofdiagnostic or therapeutic substance(s) (including  anesthetic, antispasmodic, opioid,steroid, other solution) epidural or subarachnoid; cervical or thoracic

• 62311 -- ... lumbar, sacral (caudal)

• 64408 -- Injection, anesthetic agent; vagus nerve

• 64410 -- ... phrenic nerve

• 64435 -- ... paracervical (uterine) nerve.

Faster filing: "One important reminder is that the modifier must be appended to the Column 2 code and not the lower relative value unit (RVU) code," Hammer says. In the example above, the trigger point injection  codes carry a lower RVU. If you append the modifier to the Column 1 code instead of the Column 2, however, the carrier will deny your claim. The change is retroactive back to April 1, 2009.

Other pairs with modifier indicator changes involve Column 1 codes 27096 (Injection procedure for sacroiliac joint, arthrography and/or anesthetic/steroid), 36557 (Insertion of tunneled centrally inserted central venous  catheter, without subcutaneous port or pump; younger than 5 years of age), 36558 (... age 5 years or older), and 36560-36566 (Insertion of tunneled centrally inserted central venous access device ...). All the modifier indicator changes are retroactive to April 1, 2009.

CCI 15.3 includes 18,320 new edit pairs, according to a summary report by Frank Cohen, PA, of MIT Solutions Inc. in Clearwater, Fla. "The overwhelming majority have a modifier indicator of '0,' meaning you cannot use a modifier even if you think it is appropriate," Cohen stated in a press release.

The most common codes being paired in new edits are for some moderate sedation services:

• 99148 -- Moderate sedation services (other than those services described by codes 00100-01999), provided by a physician other than the health care professional performing the diagnostic or therapeutic service that the sedation supports; younger than 5 years of age, first 30 minutes intra-service time

• 99149 -- ... age 5 years or older, first 30 minutes intra-service time

• +99150 -- ... each additional 15 minutes intraservice time (List separately in addition to code for primary service).

"Note that the majority of the new edits were for moderate sedation performed by another physician instead of the performing surgeon," Hammer says. "These new bundling edits make sense that the physician reporting the surgical procedure code should not be able to report these particular moderate sedation codes that require a different provider performing the moderate sedation services."

Pain practices: Anesthesiologists provide anesthesia during procedures, not moderate sedation -- which means you wouldn't be reporting 99148-99150 anyway. But you're in a different situation when coding pain management. Your pain management specialist becomes the "surgeon" when administering injections, so you might have reported moderate sedation for some procedures in the past.

As if keeping up with new edits isn't tricky enough, as an anesthesia or pain management coder you also have "swapped edit pairs" to change in your system.

This part of CCI 15.3 includes common procedures, such as 64450 (Injection, anesthetic agent; other peripheral nerve or branch) with 20550 (Injection[s]; single tendon sheath, or ligament, aponeurosis [e.g., plantar "fascia"]). The Column 1 and Column 2 designations for the affected pairs have flip-flopped, so pay special attention to which procedure is now comprehensive versus component.

"This is a really important point," Hammer notes. "If the provider puts the modifier on the Column 1 code in error, the Medicare contractor will deny the Column 2 code and not allow processing for payment."

Example: Previous CCI edits listed 20550 in Column 1 and 64450 in Column 2. CCI 15.3 reverses those places, with 64450 in Column 1 and 20550 in Column 2, back to an effective date of Jan. 1, 1996.

Niles R. Rosen, MD, medical director of the National Correct Coding Initiative, wrote the American Society of Anesthesiologists on behalf of CMS, explaining the Oct. 1 CCI changes before they went into effect. Highlights of the letter included:

• "CMS will modify the edits bundling epidural injection and nerve block CPT codes into certain injection/aspiration procedures (CPT codes 20550-20553, 20600-20612, and 27096) so that all edits will allow use of NCCI-associated modifiers. If a provider performs a nerve block or epidural injection unrelated to anesthesia for one of the other listed procedures, the epidural injection or nerve block code may be reported with an NCCI-associated modifier."

• "CMS will modify the edits bundling epidural injection and nerve block CPT codes into insertion of tunneled centrally inserted central venous access/catheter procedures (CPT codes 36557-36566) so that all edits will allow use of NCCI-associated modifiers."

• "CMS will modify the edit with column one CPT code 62270 and column 2 code 62310 to allow use of NCCI associated modifiers."

• "CMS will delete the edits bundling epidural injection and nerve block codes into CPT codes 31500, 36555, 36556, 36568, 36569, 36620, 36625, 93503, 93561, and 93562."

Full details: You can read the complete letter on the ASA's website (www.asahq.org). Simply click on "Practice Management" to reach the latest ASA news and scroll down to "ASA wins reconsideration of CCI edits" dated July 2, 2009