Anesthesia Coding Alert

Follow these 6 steps to handle procedure, block and aftercare coding

The case: An anesthesiologist and CRNA worked together during a shoulder arthroscopy procedure. Determine how you would you code the following case, then read what our experts recommend.

Procedure: Arthroscopy of the patient's left shoulder

Staff present: Anesthesiologist and CRNA

Anesthesia service: The team provided general anesthesia during the procedure. At the end of the procedure the anesthesiologist inserted a pain pump, which the patient had for two days following surgery. As the patient woke from general anesthesia, the anesthesiologist administered an interscalene nerve block.

Step 1: Code the Procedure's Anesthesia

Your first step in reporting the procedure is simple, says Kim Arnett, CPC, coder for Georgia Anesthesiologists PC, in Marietta, Ga. Submit 01630 (Anesthesia for open or surgical arthroscopic procedures on humeral head and neck, sternoclavicular joint, acromioclavicular joint, and shoulder joint; not otherwise specified) for general anesthesia during the arthroscopy procedure.
 
Other coders agree with this approach. "01630 is the correct code for the arthroscopy unless the physician performed it for diagnostic purposes only or the service was not for a specific procedure listed," says Donna Howe, CPC, with Anesthesiology Associates of Eastern Connecticut PC, in Manchester.

Step 2: Code the Pump's Catheter Placement

The anesthesiologist placed a pain pump, which means there must be some way for the pain medication to be delivered. This is the same as a continuous interscalene block being administered via catheter attached to a pump.

Report the catheter placement with 64416 (Injection, anesthetic agent; brachial plexus, continuous infusion by catheter [including catheter placement] including daily management for anesthetic agent administration). Because the anesthesiologist placed the pain-relief catheter on the same day as the surgical procedure, you append modifier -59 (Distinct procedural service) to procedure code 64416.

Step 3: Code the Interscalene Block

Coders disagree on whether it is appropriate to report the interscalene block that the anesthesiologist administered as the patient awoke. The key here is having documentation of the block's medical necessity, considering that the anesthesiologist had already placed the pain pump and catheter.

Documentation of medical necessity would be a written order or request from the surgeon asking that the anesthesiologist administer the block, Arnett says. The anesthesiologist can also use documentation of the surgeon's oral request for the service to support the block's medical necessity.

If you have clear documentation to support using the block, report 64415 (... brachial plexus, single). Again, append modifier -59 because the anesthesiologist performed the injection on the same day as surgery. Include the primary diagnosis code of V58.49 (Other specified aftercare following surgery).

"I can only think of one scenario where you might be able to bill and get reimbursed for both services (64415 and 64416)," Howe says. "That would be if a single injection was given on the day of surgery and some kind of special circumstance or complication required the insertion of the catheter for continuous infusion for extended pain control.
 
"Obviously, detailed documentation is important here in case there is a need for an appeal," Howe adds. "Under normal circumstances, I would not bill 64415 and 64416 in the same postoperative period."

Step 4: Skip the Aftercare

Because the anesthesiologist intends for the pain pump to be in place for two days, beginning coders might try to report aftercare service with 01996 (Daily hospital management of epidural or subarachnoid continuous drug administration) for the next-day's pump care. However, Arnett and Howe both say reporting 01996 is inappropriate.

"According to the American Society of Anesthesiologist's guide, code 64416 includes management days with a 10-day global period," Arnett says. That means you don't code any management days separately.

The same holds true for 64415 if you have the supporting
documentation to report it for the interscalene block, Howe says. It's a code for a single injection, so it  doesn't have any associated daily management.

Step 5: Report the Anesthesia Providers' Case Involvement

Because an anesthesiologist and CRNA were involved with the case, you need to report services for both professionals. Check reports from the same timeframe to determine whether the anesthesiologist was medically directing or medically supervising this case. For medical supervision, append modifier -AD (Medical supervision by a physician: more than four concurrent anesthesia procedures). Note: Appending modifier -AD is correct for these situations, but remember that physicians rarely have cases that qualify for supervision, because the reimbursement is so poor.
 
If the case qualifies for medical direction, the modifier you report depends on how many concurrent cases the anesthesiologist had. Report either modifier-QK (Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals) or -QY (Medical direction of one certified registered nurse anesthetist [CRNA] by an anesthesiologist), depending on the number of people involved in the case.

Report the CRNA's involvement during a medically directed case with modifier -QX (CRNA service: with medical direction by a physician).

Step 6: Double-Check the Details

Before submitting the claim, double-check the details to ensure you report it correctly.

"Proving medical necessity of postoperative pain control is often the biggest challenge with these types of cases," Arnett says. "Check the operative note, anesthesia record and even sometimes lab reports and x-rays for the most details about the procedure and diagnosis descriptions. This can help move a claim through faster, more efficiently and prove medical necessity to make reimbursement turnaround as quick as possible."

"Diagnosis is important, especially if you're coding a nerve block for Medicare claims," Howe says. "CMS has a rather short list of ICD-9 codes that support medical necessity. (See 'Show Nerve Block Necessity With This Quick Key' below.) The list does not include any post-surgical diagnoses, but some commercial carriers recognize the need for and benefit of postsurgical pain control for shoulder surgery."

Denial solution: If you receive a denial for post-surgical pain control, Howe recommends appealing it with copies of any reports with documentation indicating the need for a higher level of pain control than the anesthesiologist can reach with conventional means.