Anesthesia Coding Alert

Retrobulbar blocks (67500*), which surgeons sometimes request anesthesiologists to administer because theyre riskier than other ocular injections, are pretty
tricky to code particularly for Medicare and third-party carrier reimbursement.

Billing 67500* Versus Anesthesia Codes

Code CPT 67500* appears in the Eye and Ocular Surgery section of the CPT as a stand-alone procedure. I have always followed the rule of thumb that if a block or injection is the anesthesia for a surgical procedure, use the appropriate anesthesia CPT codes to report it. However, if it is a stand-alone injection or procedure, use the appropriate pain-management, nerve block or injection code instead, says Theresa Ruiz-Law, director of managed care and reimbursement for the American Association of Nurse Anesthetists in Park Ridge, Ill.

Barbara Johnson, CPC, MPC, professional coder with Loma Linda University Anesthesiology Medical Group Inc. of Loma Linda, Calif., says 67500* is used, for example, when an injection block is given to a patient with multiple facial lacerations for pain control. Its also used for unusual complications (such as a sudden increase inblood pressure) that preclude continuing surgery. If the surgery is discontinued after the administration of the retrobulbar block, code the procedure with 67500* to indicate that the injection was for pain management with no further monitoring.

In surgical situations, either the surgeon or the anesthesiologist might administer the nerve block. Often, however, the anesthesiologist is still likely to provide patient monitoring as well as additional medication to help calm the patient. Therefore, the anesthesiologist should bill the service with anesthesia codes that accurately reflect the level of care, Johnson says.

In this instance, you can bill nerve blocks only for pain management. Ruiz-Law cautions that some managed care companies will lump retrobulbar blocks into the ocular surgery payment. Other carriers consider the blocks local anesthesia and bundle it with the anesthesia code. (If the payment for a block is bundled into the surgical code, it is up to the surgeon and anesthesiologist to negotiate fees.)

Yet, in the case of eye surgeries most commonly associated with retrobulbar blocks, such as 66984 (extracapsular cataract removal with insertion of intraocular lens prosthesis [one stage procedure], manual or mechanical technique [e.g., irrigation and aspiration or phacoemulsification]), the anesthesiologists role extends far beyond administering the block. Mary Klein, coding specialist with Panhandle Medical Services of Pensacola, Fla., notes that anesthesiologists seldom administer only a retrobulbar block. In our practice, we use the pertinent anesthesia code, such as 00142 (anesthesia for procedures on eye; lens surgery), because it includes patient sedation during surgery and the level of monitoring necessary before, during and after surgery, she says. We rarely use code 67500* to report treatment our anesthetists provide.

Track and Document Time for Accurate Billing

Payers reimburse most CPT codes (such as 67500*) based on the relative value unit (RVU) payment system, which has a set fee for each procedure. Anesthesia reimbursement, however, is based on unit value a base unit charge plus the amount of time the patient was under the care of the anesthesiologist (time units). Every anesthesia code (00100-01999) has an assigned base unit value.

Insurers establish the time units. Some commercial carriers consider 10 minutes as one unit, and others, such as Medicare, generally recognize 15 minutes as one unit. Under CPT and Medicare guidelines, if an anesthesiologist provides 30 minutes of care for a patient undergoing cataract surgery and reports 00142, reimbursement is calculated using the base unit value of code 00142 (four base units) plus two units of time (30 minutes = two units), for a total of six units.

Some local Medicare carriers allow time-unit calculations rounded to the nearest 10th of a unit, while commercial carriers might allow rounding to the nearest whole-value unit. Remember that payers reimburse the service not the type of anesthesia, whether it is MAC, general anesthesia or a nerve block, such as the retrobulbar block.

Johnson advises coders to include in the documentation specific information regarding the services performed. Anesthesiologists should note the time they began to prepare the patient for the block, the actual time the block was administered and the time spent with the patient. They should also note if someone else placed
the block.

A retrobulbar block, like other nerve blocks, cannot be billed separately if it is administered as monitored anesthesia care (MAC) for cataract or other surgeries. Instead, anesthesiologists should bill their time with the appropriate anesthesia code, even if care was provided in discontinuous time segments. For example, if the anesthesiologist placed a block from 7:50 until 8 a.m., then returned to monitor the patient from 8:30 until 9:20 a.m., billing is for the 60 minutes spent with the patient.

When submitting Medicare claims for MAC, include the MAC modifier -QS (monitored anesthesia care service). Some Medicare carriers also require that you include modifiers -G8 (monitored anesthesia care for deep complex, complicated, or markedly invasive surgical procedure) or -G9 (monitored anesthesia care for patient who has history of severe cardiopulmonary condition) with MAC claims when appropriate.

If the claim involves nerve blocks for pain management, be sure the first ICD-9 code is for pain, such as 379.91 (ophthalmic pain). Coders should follow CPT and anesthesia guidelines and check with their local Medicare and commercial insurers for correct codes and reporting and processing policies.