Anesthesia Coding Alert

Working in a childrens hospital or working with pediatric patients in general hospitals has many benefits and some special challenges not found with treating adult patients. One of these is how to handle anesthesia consults related to pre-procedure workups.

If a pediatric patient is scheduled for an invasive procedure, such as a cardiac catheterization (cath), the anesthesiologist and treating physician may study the childs medical history and current condition prior to the procedure to determine whether he or she will need a general anesthetic, monitored anesthesia care (MAC) or no anesthesia. If a decision is made not to use anesthesia, an anesthesiologist may or may not be nearby during the procedure due to other patient cases. That means appropriate anesthesia assistance may not be readily available if the childs situation calls for it once the procedure begins. Because its even more crucial to have the appropriate help nearby with pediatric patients than with adults, some hospitals have begun implementing some new procedures that have an anesthesiologist on hand for all pediatric invasive procedures. But its better to head off problems than handle them, so pre-op workups are getting even more attention.

The Standby Service Option

The anesthesiologists at Childrens Hospital of Philadelphia are required to perform extensive cardiac workups on children prior to invasive cath procedures, says Margie Fahy, CPC. Doing a pre-op workup is standard practice to be sure the child will be able to handle anesthesia if its called for, she says. Then the anesthesiologist is scheduled for standby service during the procedure in case its needed.

Providing standby service means that the anesthesiologist or another member of the anesthesia team (an attending or a fellow) is actually present in the room during the childs procedure. An anesthesiologist is available during similar procedures with adults, but not usually in the same room unless needed. The staffs at many childrens hospitals have established the standby protocol to ensure that help is close at hand in case they need to anesthetize emergently.

Note: Code 99360 is used for physician standby services that involve prolonged physician attendance without direct (face-to-face) patient contact. The physician may not be providing care or services to other patients during this period. The code is used to report the total amount of time spent by a physician on a given day on standby. It is billed at a flat fee in 30-minute increments.

Billing for Pre-Op Consults

If anesthesia is used during the childs procedure, Fahy says, the patient is billed for that service but not the original pre-op consult. The challenge lies in determining when and if the patient should be billed for the consult if anesthesia services are not used.

We never billed for the consult in the past, whether we actually administered anesthesia during the procedure or not, she says. We also cant bill for it if the consult results in surgery during the childs hospital stay, because the consult would be included in the surgical anesthesia service. But the anesthesiologist or CRNA can spend a lot of time with a case as standby, not be needed, and not be reimbursed for any of that time. Now were beginning to set guidelines for when to bill for the consult if the standby service is provided but isnt used.

Brenda Wesley, patient account coordinator for Pediatric Anesthesia Associates at Childrens Hospital Medical Center in Cincinnati, OH, agrees that the physicians or CRNAs time should be reimbursed in some way. We dont offer a standby service option, but we do bill for the consults when its appropriate, she says. The physicians decide up front whether anesthesia will be needed during the procedure and at that point either offer monitored anesthesia care or a general anesthetic.

Each hospital interviewed stresses that the guidelines for billing consults in this situation can vary from state to state, and even from one institution to another. A Medicare Medical Policy Bulletin in Pennsylvania from June 1991, which hasnt changed since, states that payment may be made for an anesthesia consultation in either of two circumstances:

The consultation results in a decision not to administer anesthesia during the hospital stay and documentation of the circumstances is provided; or

the consultation is not preparatory to surgery, such
as for respiratory problems, when anesthesia will definitely be used.

Coders should check with their local carriers, but Wesley says the following codes may be accepted for consults that dont result in anesthesia services:

99241-99245: office or other outpatient consultations for a new or established patient (i.e., an office consultation with a patient who is complaining of palpitations and chest pains prior to a cardiac cath);

99251-99255: initial inpatient consultations for a new or established patient (i.e., an inpatient hospital consultation with a patient who develops acute respiratory distress syndrome following a mitral valve replacement).

Make sure the three key consultation elements are executed:

1. a request for opinion or advice about a patient from one physician (or other appropriate source) to another;

2. performance and documentation of that service by the consultant; and

3. communication of the opinion or advice back to the
requesting physician.