Anesthesia Coding Alert

If the visit qualifies as a consult, report the appropriate code from 99241-99245 for an office or other outpatient consultation for a new or established patient; report 99251-99255 for an initial inpatient consult.
 
If the visit does not meet the "Four R's" criteria, it's not a consult. Instead, you report it as a new patient or follow-up visit, depending on the circumstances. This includes E/M codes 99202-99205 for a new patient office or outpatient visit or 99212-99215 for an established patient visit.
 
Caution: "Be careful when the report reads 'referred for nerve block' or similar wording," says Margaret Lamb, RHIT, CPC, an anesthesia coder with Great Falls Clinic in Great Falls, Mont. "This is just stating for the physician to do the procedure (which means the need for the block has already been determined) and send the patient back. It doesn't indicate a request for an opinion."

Append the Correct Modifier

If you're able to bill the consult with the procedure, you'll need a modifier to distinguish the two services. Appending modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) is typically sufficient to be reimbursed for both services. In the case of our listserv question, though, some coders suggested that Medicare might be looking for modifier -57 (Decision for surgery) appended to the appropriate E/M code instead because the physician made a "decision for surgery" within 24 hours of the patient's  initial visit.
 
Take note: Reporting modifier -57 usually applies only to surgeries that are considered to be "major" - ones with a 90-day global period - and most pain center procedures don't have 90-day global periods. Only append modifier -57 in these situations when the procedure has a 90-day global period. A neurosurgeon in a pain management group might perform a procedure with a 90-day global period, but anesthesiologists don't perform procedures with such large global periods, says Scott Groudine, MD, an Albany, N.Y., anesthesiologist.
 
Tip: Virtually all of the procedures that qualify for modifiers in these situations will use modifier -25, Lamb says. Just remember that modifier -25 only applies to E/M codes, not the actual procedure codes.

Divide Your Diagnoses

You should also consider whether separate diagnosis codes are necessary for each part of the visit. If so, some coders recommend that you report the consult diagnosis according to where the patient has pain (lower back, leg, shoulder, etc.) and the injection (or other procedure) based on the problem being treated (herniated disk, stenosis, etc.). Some of this information will depend on the patient's MRI results or other medical history factors.
 
Example: A patient comes for the consult or office visit due to low back pain (724.2, Lumbago). Upon examination, the physician determines that lumbar spinal stenosis (724.02, Spinal stenosis, other than cervical; lumbar region) is causing the pain. He administers an epidural that same day to relieve the patient's pain.
 
Report the appropriate E/M visit level (from 99241-99245 if the case qualifies as a consult, or 99201-99205 if it doesn't) and link it with diagnosis 724.2. Code the epidural injection as 62311 (Injection, single [not via indwelling catheter], 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; lumbar, sacral [caudal]) and link it with diagnosis 724.02. 
 
Another opinion: Some professionals disagree with coding a symptom code when you have a definitive diagnosis, unless you have instructions in writing from the carrier telling you to do so. "Generally, you will have a symptom and the physician establishes a diagnosis," Lamb says.
 
Lamb says to report the consult code (99241-99245) with modifier -25 for the initial visit and only link ICD-9 codes to actual diagnoses.
 
"It's good that the ICD-9 code explains why the physician is performing the procedure," Groudine agrees. A diagnosis that helps explain the procedure's necessity could influence how easily the insurer is willing to pay for it, he says.
 
Example: A patient schedules an appointment because of low back pain and the physician diagnoses spinal stenosis. During the visit, the patient mentions some hip joint pain, and the physician decides to administer a joint injection. Report diagnosis codes 724.02 and 719.45 (Pain in joint; pelvic region and thigh) with the E/M consult code. Only report 719.45 in conjunction with the joint injection (20610, Arthrocentesis, aspiration and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]).
 
After you've determined how many diagnosis codes are appropriate for the visit, you have almost all the pieces of the puzzle. Your last step is to pinpoint the best diagnoses - the ones that justify the service, accurately describe the procedure and help you achieve optimal reimbursement. For some hands-on tips for homing in on the most specific diagnoses, read "Search for ICD-9 Specificity When Coding PM Procedures" on page 29.