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 or undergoing an unusually difficult endoscopic procedure, include diagnoses 530.9 (Unspecified disorder of esophagus), 537.9 (Unspecified disorder of stomach and duodenum) or 569.9 (Unspecified disorder of intestine). You should also include a report explaining the unusual circumstances.

• For patients undergoing dilation of their esophagus because of cancer or stricture/stenosis, include diagnoses 150.9 (Esophagus, unspecified) or 530.3 (Stricture and stenosis of esophagus).
 
• When the anesthesiologist administers IV Propofol or a paralytic agent during the endoscopic procedure, include diagnosis V58.83 (Encounter for therapeutic drug monitoring). "Obviously, a patient given a paralytic needs anesthesia there to provide the service, ventilate and transition the person back to spontaneous independent respiration when the therapeutic muscle relaxant wears off," Groudine says.

"CPT lists the EGD codes in the summary of codes that include conscious sedation," Shiley says. "It states that 'when clinical conditions of the patient require such anesthesia services' such as monitored anesthesia care, you can report anesthesia codes 00100-01999."

What it means: In other words, if a screening diagnosis or treatment of commonly found conditions is used instead of the clinical condition requiring anesthesia, carriers will not/should not pay these services separately, Shiley says.

"If the surgeon requests that we participate in EGD procedures, we document the necessity by the diagnosis requiring our presence, such as anxiety, dementia, spastic disorders, etc," Shiley adds.

Caution: Being instructed on which diagnoses to include with your claim doesn't guarantee reimbursement. For example, Empire's policy states that "these claims will be reviewed to determine whether the anesthesia service is reimbursable." Be sure you know your own carrier's stance on review and reimbursement.

Consider an ABN for Some Carriers 

Because so many carriers don't reimburse for anesthesia for every EGD procedure, some physicians have their patients sign an Advance Beneficiary Notice (ABN) beforehand, stating that the patient will pay for the service -- if the carrier in question accepts ABNs.

"ABNs can be useful for Medicare patients if the physician provides sedation that is not considered medically necessary," Shiley says. "We do not use an ABN for commercial carriers, [because a] noncovered service is typically the patient's responsibility."

Groudine reminds that if you have an ABN, you must submit it at the time of billing -- but realize that this can delay processing.

"If your care is within the approval policy of the carrier, I would not file an ABN, but I would fight for the reimbursement I'm due for being in compliance with the rules," Groudine says. "If a condition arose that was not covered by the policy, then using an ABN is probably a good idea."

"Patient safety should always be the highest concern," Shiley adds. "For that reason, some surgeons are more comfortable having anesthesia providers involved with their patient's care. This, however, results in more costs to the insurance carriers. That's where the conflict arises and why medical-necessity requirements are becoming more stringent to restrict payment of this service for anesthesia."
 
Bottom line: Monitor your carriers' requirements frequently and do not enter into providing anesthesia during EGD procedures without knowing the carriers' documentation and reimbursement issues.