Anesthesia Coding Alert

Tip: Knowing each line's purpose can help your chances of separate pay.

Getting paid for anesthesia during cardiac cases often isn't as complicated as some other procedures -- until your provider starts using multiple monitoring lines. The next time your anesthesiologist uses a Swan-Ganz catheter during cardiac surgery, follow these tips for claims success.

1. Understand Each Line's Purpose

An anesthesia provider often uses multiple lines during complicated heart cases, for different purposes. The most common categories include:

• A Swan-Ganz catheter (93503, Insertion and placement of flow directed catheter [e.g., Swan-Ganz] for monitoring purposes) monitors pulmonary artery pressure and measures cardiac output and other cardiovascular functions. Anesthesiologists typically place a Swan-Ganz in patients who have some type of cardiac condition, or whose cardiac function might be compromised prior to or during surgery, says Judy A. Wilson, CPC, CPC-H, CPC-P, CPC-I, CANPC, CMBSI, CMRS, business administrator for Anesthesia Specialists, PTR, in Virginia Beach.
• A central venous pressure (CVP) line (36556, Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older) gives your provider additional IV access to the patient's central veins. The anesthesiologist usually places a CVP line in the patient's superior vena cava, and may use it for multiple purposes, including IV fluid delivery, to adjust the patient's blood volume, or for central drug infusion.
• An arterial line (36620, Arterial catheterization or cannulation for sampling, monitoring, or transfusion [separate procedure]; percutaneous) monitors and records the patient's blood pressure.

2. Check Documentation for Correct Number of Lines

You can always report arterial lines in addition to any CVP or Swan-Ganz lines. Having other types of lines documented in a patient's case, however, doesn't mean you automatically report each one.

Explanation: When an anesthesiologist places a Swan-Ganz catheter, he runs it through the CVP line. Correct Coding Initiative (CCI) edits list the CVP line as part of the Swan-Ganz. As such, you normally report only the Swan-Ganz placement with 93503 instead of coding for both lines.

Exception: You can report both the central line and the Swan-Ganz if your provider documents separate locations and separate line placements for the central line and Swan-Ganz catheter. Append modifier 59 (Distinct procedural service) to the central line code, 36556 (or 36555, Insertion of non-tunneled centrally inserted central venous catheter; younger than 5 years of age).

Example: Your anesthesiologist places a Swan-Ganz catheter to monitor cardiac output, and places a CVP line separately because of the need for multiple central vein IV access. If documentation clearly shows that the lines were placed separately and had separate purposes, you can report both lines.

3. Skip X-Ray Confirmation Coding

A physician often will use a chest X-ray to confirm accurate Swan-Ganz catheter placement. Do not include a code such as 71010 (Radiologic examination, chest; single view, frontal) on the claim, even if the anesthesiologist clearly documents the service. The CCI manual addresses this issue in Chapter 11, Section I.24, says Kristi Stumpf, MCS-P, CPC, COSC, ACS-OR, owner of Precision Auditing and Coding.

Explanation: Insertion of Swan-Ganz and other flow-directed catheters "is often followed by a chest radiologic examination to confirm proper positioning of the flow directed catheter. A chest radiologic examination CPT^{® code (e.g., 71010, 71020 [Radiologic examination, chest, 2 views, frontal and lateral]) should not be reported separately for this radiologic examination," the manual states.}

4. Rely on Patient Condition to Support Necessity

Your provider's documentation should include the specific reason why Swan-Ganz monitoring is necessary. Review the patient's chart and medical history for potential diagnoses that would support medical necessity. These might include:

• 410.xx (Acute myocardial infarction)
• 415.0 (Acute cor pulmonale)
• 416.0 (Primary pulmonary hypertension)
• 428.xx (Heart failure)
• 518.5 (Pulmonary insufficiency following trauma and surgery).

If any of the acceptable diagnoses applies to your patient, talk with your anesthesiologist about whether you can legitimately list it on the claim. If you don't have a specific diagnosis, your best option often will be 414.01 (Coronary atherosclerosis of native coronary artery).