Anesthesia Coding Alert

Compare your solutions to those of our expert coders.

How did you do? It always pays to keep up with the trickier aspects of neurology coding, so dive in and check these answers to those you came up with.

Solution 1: True. If the services are provided by your anesthesiologist, as long as the continuous infusion is not used as the mode of anesthesia for the surgery, the pain management procedure should be separately billable, says Pamela Linton, CPC, anesthesiology coding specialist with Medical Management Professionals in Chattanooga, Tenn. "For dates of services in 2008, the two days of rounds afterward are not separately billable, as the procedure code 64448 has a 10-day global period," Lin-ton adds.--

If the catheter for the femoral block was inserted at the time of surgery for post-operative pain management, you should bill it out as 64448 (Injection, anesthetic agent; femoral nerve, continuous infusion by catheter [including catheter placement]) and remember to append modifier 59 (Distinct procedural service) to indicate to the payer that the continuous infusion was separate and distinct from the anesthesia services. For the diagnosis code to link medical necessity, you may need to look at diagnosis code 338.18 (Other acute postoperative pain).

Code 338.18 tip: The ICD-9 guidelines specifically state that acute postoperative pain diagnosis codes should not be reported for routine or expected postoperative pain immediately after surgery.

In this scenario, the doctor may suspect the patient, with narcotic tolerance due to long-term use for another condition, will have an unusual amount of postoperative pain that is neither expected or routine for typical patients. Postoperative pain should be reported as the principal diagnosis when the reason for the encounter is postoperative pain control management. It may also be assigned as a secondary diagnosis code when the patient presents for outpatient surgery and develops an unusual or inordinate amount of postoperative pain.

Note: Due to the 2009 CPT deletion of the phrase "including daily management for anesthetic agent administration" from the code description for 64448, the global days for the continuous infusion code will change to zero days for 2009.

Solution 2: A. Rheumatic fever following an untreated Streptococcus bacterial infection used to be the leading cause of valve disorders before antibiotic usage became widespread. Heart valves can become swollen and scarred when they're attacked by strep antibodies, making the valves susceptible to insufficiency or stenosis. ICD-9 provides different codes based on the type of valve disorder that is associated with rheumatic fever. You'll need to go a little further with 395.x (Diseases of aortic valve), coding the necessary fourth digit for an ultimate diagnosis of 395.0 (Rheumatic aortic stenosis).

Remember: You should use 01926 (Anesthesia for therapeutic interventional radiological procedures involving the arterial system; intracranial, intracardiac or aortic), which is 10 units, for your anesthesiologist's work during the valvuloplasty.

Solution 3: False. You should not report 99116 if your anesthesia code description already implies hypothermia.

For example: Your anesthesiologist uses a pump oxygenator to accomplish hypothermia and rewarming following a CABG procedure on a patient younger than 1 year of age. You should report 00561 (Anesthesia for procedures on heart, pericardial sac, and great vessels of chest; with pump oxygenator, younger than 1 year of age) and 00562 (... with pump oxygenator, age 1 year or older) for this encounter.

Also worth noting: Use 00563 (... with pump oxygenator with hypothermic circulatory arrest) when reporting deep hypothermic circulatory arrest (DHCA) that halts blood circulation performed with CABG.

Heads up: Hypothermia is bundled with 00561-00566, so you won't report these codes along with 99116. Because hypothermia promotes cardiac arrhythmia and anesthesiologists wouldn't perform this off pump, pump oxygenator codes 00561-00563 are the most important for you to watch for.

Solution 4: False. However, assuming you are coding for your anesthesiologist rather than for a facility, you may be able to append modifier 53 (Discontinued procedure) to the anesthesia code. Modifier 53 is reserved for situations when your anesthesiologist sees a risk threatening the patient's health if the procedure continues. The provider can cancel the procedure at any one of three points:

1. Preoperative visit: Your anesthesiologist completes the standard preoperative visit but believes the patient is not a good candidate for the recommended surgery. He discusses the situation with the surgeon, and the surgeon cancels the case. If the rescheduled date is far enough in the future to merit another complete pre-op consult (usually at least two or three weeks later), bill the original exam with the appropriate consultation code (99241-99245 for office/outpatient or 99251-99255 for inpatient).

The second consult (when the case actually takes place) is considered part of the anesthesia service at the time of surgery.

2. Before induction: If your anesthesiologist sees an arrhythmia before the case begins (for example, when he begins monitoring the patient), the surgeon may cancel the case so the patient can be evaluated and rescheduled.

When canceled after the patient is prepared for surgery but before induction, report 01999 (Unlisted anesthesia procedure[s]) with modifier 53 (a three-unit reimbursement).

3. After induction: If your anesthesiologist induced the patient but saw a sudden drop in blood pressure, for example, he may advise the surgeon the case should not proceed. In this case -- cancelled after induction of anesthesia -- use the CPT code and append 53 (base unit + time).

Remember: You cannot append modifier 53 if the patient elects to cancel the procedure prior to anesthesia induction.

You should also check with your local carriers to determine whether special billing rules apply for canceled anesthesia cases.-There is no national policy, and carrier requirements range from consultation and E/M codes to reporting either the anesthesia code for the intended-surgery or-an unlisted anesthesia service.

How modifier 74 enters: If you are coding for a facility (hospital, ambulatory surgical center), modifier 74 (Discontinued outpatient hospital/ambulatory surgery center [ASC] procedure after administration of anesthesia) may be applicable, since it is reserved for hospital or ASC outpatient use. But you must be billing for the facility.

Solution 5: True. A single level for paravertebral facet joint injections can be an injection into the joint itself (intra-articular) or two injections blocking each of the paravertebral facet joint (medial branch) nerves.

For example: Your pain management specialist performs diagnostic nerve blocks of the C3 and C4 medial branches (blocking the C3-C4 facet joint). That is only one level. You should report only 64470 (Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; cervical or thoracic, single level) for those injections, says pain management specialist Richard Kennedy, MD, in West Covina, Calif.

Another example: Now let's say your pain management specialist performs injections of local anesthetic of the C3, C4, and C5 medial branches. Now she is addressing three nerves but only two "joints;" that is, C3-C4 and C4-C5. Count each joint as one level, and use +64472 (... cervical or thoracic, each additional level [List separately in addition to code for primary procedure]) for the second injection.