Anesthesia Coding Alert

Payer policies differ on upper GI and colonoscopy screening, so check with yours first.

Reporting your anesthesiologist's work during an upper gastrointestinal endoscopy, esophagogastroduodenoscopy (EGD), or colonoscopy procedure is a thorny issue for many coders. If your anesthesiologist provides service during one of these procedures, you'll need to consider a number of factors in order to get reimbursed. These five expert tips should help you submit worry-free EGD claims.

1. Clear Anesthesia Coverage With Your Payers

Insurance companies have varying viewpoints on whether they reimburse for EGD anesthesia. That's why verifying your payer's policy is a good starting point. Many payers consider EGD conscious sedation anesthesia to be the responsibility of the endoscopist or gastroenterologist, says Joanne Mehmert CPC, CCS-P, president of Joanne Mehmert & Associates in Kansas City, Missouri. These payers believe "the endoscopist can supervise a qualified person to monitor the patient and administer pain medication during the procedure." In fact, reimbursement is included in the endoscopist's global fee.

Local coverage determinations for other payers, such as Medicare, might dictate more specifically whether they'll reimburse for anesthesia. Medicare currently does not have a national policy on reimbursement of endoscopy. When an anesthesiologist renders services that the surgeon could normally provide, such as local or IV sedation, the risk of denial increases.

Some payers will pay for all anesthesia care during endoscopy. "Many have adopted a position that routine colonoscopy can be done safely by the endoscopists and therefore will only pay when the patient or procedure warrants additional care," says Scott Groudine, MD.

professor of anesthesiology at Albany Medical Center in New York. For example, if the procedure is an endoscopic retrograde cholangiopancreatography (ERCP), some insurance companies will pay for anesthesia regardless of the patient's condition, Groudine says.

2. Look for Crosswalks with 00810 and 00740

The code range for upper gastrointestinal endoscopies (EGDs) and esophagogastroduodenoscopies (43234-43259, Upper gastrointestinal endoscopy...) cross to anesthesia code 00740 (Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum). You'll also use 00740 for ERCP services (43260-43272, Endoscopic retrograde cholangiopancreatography [ERCP]...).

Colonoscopy surgical codes 45378-45392 (Colonoscopy, flexible, proximal to splenic flexure...) cross to 00810 (Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum).

3. Ensure Dx Points to Medical Necessity

Denials for colonoscopy anesthesia often happen because the diagnosis does not meet the payer's criteria for payment. Some insurance companies will reimburse for anesthesia during the  ervice, but they require documentation supporting medical necessity, such as a physical status modifier of P3 (A patient with severe systemic disease) or higher. Other payers list specific conditions and diagnosis codes that you must use to warrant anesthesia payment. Plus, some will pay for specific interventions done by the anesthesiologist, such as use of a paralytic like Propofol or Fospropofol.

Reason: "The FDA has warned against the use of these drugs by non-anesthesia providers," Groudine says. Some payers require that the diagnosis (which is listed in the local coverage determination) must support anesthesia when given by the anesthesiologist. If the anesthesiologist provides monitored anesthesia care (MAC), you would append the MAC modifier (QS). All diagnoses must link to the procedure.

Roadblock: If the medical record does not allow you to code to the required level of specificity, check with the reporting physician for guidance.

4. Use V Codes for Diagnosis Support

The V-code section of ICD-9 may offer help in providing the correct diagnosis codes.

You may be in the habit of using V codes as secondary codes only, but for some EGD and colonoscopy cases the V code might be the only appropriate primary diagnosis.

Example: Some payers allow reimbursement for anesthesia during endoscopy procedures if you submit V58.83 (Encounter for therapeutic drug monitoring). Still other payers will approve screenings for personal or family history of malignancy.

Check the V-code section for screening and "history of malignancy." For example, you might report personal history of laryngeal cancer with V10.03 (Personal history of malignant neoplasm; esophagus).

Option: You might also apply a new V code -- V15.80 (Personal history of failed moderate sedation) -- to explain a previous failure of conscious sedation and justify the presence of an anesthesia provider.

Good practice: Use V codes to provide additional clinical information to any insurer, whether you're dealing with Medicare or a private payer. Just keep in mind that V code approval in the past doesn't mean you will get automatic approval for it now.

5. Prepare to Appeal

By including supporting diagnoses and physical status modifiers, you may help get your EGD claims approved more easily. But you may also have to appeal some cases that get a medical review, even if some payers accept anesthesia services for EGDs. "There is literally never a 'one shoe fits every circumstance,'" Mehmert says.

If you're not finding the right codes based on your anesthesiologist's notes (and then getting denials), you might try offering suggestions to your physician. Create a list of patient conditions with descriptions, based on the most common ones allowed by your insurers.

Caveat: You should only list diagnoses that are actually reported in the encounter notes. You can't select ICD-9 codes just because they match the insurer's policies. You might also have the patient sign an advanced beneficiary notice (ABN), informing him that he may be responsible for the charges if his insurance rejects the claim.

Caution: You can only use the ABN option if the patient's insurance allows it.