Anesthesia Coding Alert

Check your base units to avoid audit troubles

Even if upcoding claims (miscoding procedures and bringing your group higher reimbursement than appropriate) is an honest mistake, your group can pay the price if the same errors keep cropping up.

Zero in on these three coding areas to help keep your claims on track and your bottom line honest: 

• Reporting a higher base for a procedure that's not accurate
• Failing to use unlisted-procedure codes
• Coding incorrectly because of insufficient documentation.

Double-Check Your Base Units' Accuracy

The American Society of Anesthesiologists and other groups offer resources to help you report each procedure's base units, but incorrect amounts still find their way to carriers. Having someone on staff who is certified or well-versed in coding to oversee the process can help you steer clear of such basic errors, says Jann Lienhard, CPC, an anesthesia coding consultant in Marlton, N.J.

Why it matters: Anesthesia providers multiply a dollar amount by each procedure's base units to determine part of their reimbursement. Procedures with higher base units lead to higher reimbursement. Working higher base units into your reimbursement equation looks good on your bottom line but doesn't hold water when an auditor discovers the mistake.

When you see it: You frequently see misreported units for intracranial procedures, back or spinal procedures and intrathoracic versus closed chest procedures, says Mary Klein, CPC, of Panhandle Anesthesia in Pensacola, Fla. Lienhard adds critical care and E/M services to the list.

Examples: Anesthesiologists often participate in spinal tap procedures. Coders sometimes report 00630 (Anesthesia for procedures in lumbar region; not otherwise specified) with 8 base units, but the more appropriate choice is 00635 (... diagnostic or therapeutic lumbar puncture) with 4 base units.

An even bigger difference in base units shows if you report 00500 (Anesthesia for all procedures on esophagus) with 15 base units for an esophagoscopy with lesion removal, when you should report 00520 (Anesthesia for closed chest procedures; [including bronchoscopy] not otherwise specified) with 6 base units.

How to avoid it: Read code descriptors completely before choosing your anesthesia code, Klein says. Talk with your providers if they write incomplete or inaccurate procedure descriptions in the chart. Lienhard adds that you should keep up-to-date with CPT criteria, especially when coding critical care or E/M services.
 
"CPT is specific on these items, and many providers do not take the time to analyze what they are doing and what they are coding for," she says. "Review the notes yourself instead of simply taking the provider's word for what the codes should be."
 
Don't Shy Away From Unlisted-Procedure Codes   

As a coder, your must report each procedure with the most accurate code possible. Resorting to unlisted-procedure codes (such as 01999, Unlisted anesthesia procedure[s]) can go against your grain but is sometimes necessary.

Why it matters: CPT instructs you to report codes that are true to the service provided, not something similar. "Many coders and providers are afraid of the appeal (which is necessary) when using unlisted codes," Lienhard says. "They are sure there is something describing the services rendered, and they usually find something that's close--but this is not horseshoes."

When you see it: Using unlisted-procedure codes doesn't happen as often in anesthesia as in other specialties, Klein believes, because the anesthesia codes are general enough to cover a broader range of procedures on any given body part. Pain management coders can fall in the trap when reporting services such as radiofrequency of the dorsal root ganglion.

CPT does not include a code for this, so some coders lean toward submitting a code for paravertebral facet joint nerve (64622-64627, Destruction by neurolytic agent, paravertebral facet joint nerve ...). The dorsal root ganglion is not the same structure described by these codes, so you should report 64999 (Unlisted procedure, nervous system) instead.

The up side of unlisted-procedure codes: Reporting unlisted-procedure codes means additional work because you must submit more documentation to support the claim--and often go through appeal. Many carriers won't reimburse for them, which raises frustration levels. But CPT will never include codes for these procedures if the AMA is unaware of the need. "If enough providers are reporting a new procedure that requires use of an unlisted code, eventually the procedure will be assigned its own code or added into the descriptor for an existing code," Klein says. 

Encourage Clear and Complete Documentation

Lienhard and Klein agree that insufficient documentation is one of the most common errors they see regarding upcoding.

Why it matters: Coding is all about the details, and you can't code accurately without them. Insufficient documentation--whether it's related to the procedure performed, the time spent with the patient or other factors--complicates your job. Not having enough information can lead to upcoding because you assume the physician performed certain services that he didn't.

Conversely, not having enough information can also lead to undercoding because you don't realize the extent of the physician's services. Either situation leads to incorrect claims and potential problems.

Example 1: Your anesthesiologist sees a hospital patient for pain management the day after surgery. The visit is a consultation, but you need to know more before coding. "What level is it?" Lienhard asks. "It was a basic request and reason for the consultation, but the provider's notes and actions must carry the level of consultation. Usually it does not." Timed notes are especially helpful in these situations because the length of the visit can give you insight into its complexity.

Remember that the other elements of E/M coding must also be there to support whichever level you bill (history, review of systems, past medical and family history, examination, medical decision-making, and risk of morbidity and mortality). These factors are usually low in a post-op pain consult, so the best code in most situations is 99251 (Initial inpatient consultation for a new or established patient ...).

Caution: Don't forget that CPT 2006 no longer includes follow-up consultation codes. Now you report a follow-up hospital visit instead (99231-99233, Subsequent hospital care, per day, for the evaluation and management of a patient ...).
 
Klein often sees insufficient documentation with anesthesia services provided during arthroscopic procedures on knees and shoulders. "We often only see 'knee scope' as the procedure," she says. "We need to know if it was diagnostic or surgical scope. Incomplete descriptions of the surgical procedures are the biggest problem we have when it comes to choosing accurate anesthesia codes." Train your providers to include more detailed descriptions to steer you toward the correct code.

Example 2: In the case of a "knee scope," Klein says most procedures include a meniscectomy or chondro-plasty. You report this with 00400 (Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; not otherwise specified) at 4 base units.

But if the surgeon performs a diagnostic scope instead, you should report 01382 (Anesthesia for diagnostic arthroscopic procedures of knee joint) with 3 base units. A difference of one base unit might not seem like much, but miscoding multiple cases can add up, especially in an ambulatory or outpatient setting with many of these cases. 

"The provider was there for the whole procedure and knows what happened," Klein says. "They need to provide that information to the coder or biller."