Anesthesia Coding Alert

What you need to know before filing claims  Providing anesthesia during esophagogastroduodenoscopy (EGD) procedures is one of the hottest issues in anesthesia reimbursement and coding these days. If physicians ask your anesthesiologist to provide this service, be sure you're up to speed on the latest carrier perspectives. Verify Anesthesia Coverage Beforehand Carriers have differing viewpoints on whether they reimburse for EGD anesthesia. That makes your road to reimbursement difficult, but it isn't impossible. Start the process by verifying your carrier's policy:

• Some carriers will reimburse an anesthesiologist for the service, but they require documentation supporting medical necessity (such as a physical status modifier of P3 [A patient with severe systemic disease] or higher).

• Many carriers consider EGD anesthesia to be the gastroenterologist's responsibility. "Aetna and Cigna are working on medical-necessity policies, and Blue Cross/Blue Shield will not pay in an office setting," says Julee Shiley, CPC, CCS-P, CMC, ACS-AN, compliance manager for Critical Health Systems Inc. in Raleigh, N.C.

• Still other carriers -- such as Medicare -- might or might not reimburse for anesthesia during the procedure, depending on the local policies. Example: Medicare will reimburse for your physician's service in many states such as New York if the anesthesiologist uses Propofol, because the drug's warning states that "Propofol should be administered only by individuals qualified in the use of general anesthetics ..." 

"Therefore, a GI doctor using this drug is violating the FDA recommendation," says Scott Groudine, MD, an anesthesiologist in Albany, N.Y. "Additionally, many state boards have decided that a non-CRNA nurse cannot administer Propofol, even under direct medical supervision." States with these restrictive policies include New York, Alabama, Arizona, Tennessee and others, so be sure your coding -- and your group's administration practices -- follows your local guidelines.

Submit the Appropriate Codes If you file a claim for EGD anesthesia, be sure you code according to when the physician introduces the endoscope:

• 00740 -- Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum; or

• 00810 -- Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum.  Your diagnosis code should indicate the co-existing medical condition that justifies your anesthesiologist's involvement in the case, not the gastrointestinal condition leading to the endoscopy. Conditions that can help justify medical necessity include:

• Parkinson's disease (332.0)

• Heart conditions (such as 410.xx, Acute myocardial infarction; or 427.41, Ventricular fibrillation)

• Mental retardation (318.x)

• Seizure disorders (such as 780.39, Other convulsions)

• Anxiety (such as 300.0x, Anxiety states). Document Unusual Circumstances     Unusual circumstances merit their own codes to show the need for anesthesia during EGD procedures. Many carriers, such as Empire Medicare in New York, specify how you should handle these special cases:

• For patients with unusual amounts of pain or discomfort [...]