Anesthesia Coding Alert

 Follow these 5 steps on difficult procedures

The Anesthesia Crosswalk helps you determine the correct anesthesia code for a procedure, but how do you choose between multiple appropriate options? Follow these steps to avoid being tripped up by choices.

1. Start With the Correct Procedure Code 

Your first step when coding any anesthesia service is to track down the correct CPT surgical code for the procedure. Base this code on medical record documentation (anesthesia records, op notes and other medical records).
 
If the surgeon performs multiple procedures during the session, select a CPT procedure code for each. “Although you typically only bill one anesthesia code, starting by coding all procedures performed in the session gives you all possible code selections to choose from,” says Samantha Mullins, CPC, MCS-P, ACS-AN, manager of coding and compliance with VitalMed in Birmingham, Ala.
 
2. Go to the Crosswalk

The Anesthesia Crosswalk, published annually by the American Society of Anesthesiologists, is one of your most important coding tools. In it, you’ll find every current CPT surgical code and the related anesthesia code(s). Although using the Crosswalk to determine your code sounds simple, your choices aren’t always cut-and-dry.
 
Look up each of the procedure’s surgical codes you selected earlier to identify the default anesthesia codes . If the same anesthesia code keeps popping up, that’s often a good sign that it’s the correct code for you to report, says Barbara Johnson, CPC, MPC, owner of Real Code Inc. in Moreno Valley, Calif.
 
Some procedures only list one anesthesia code, but others …quot; especially procedures that have a variety of anatomical options or management options …quot; can have multiple anesthesia code choices.
 
Example: The surgeon performs lesion excisions in many locations, so the Crosswalk lists many potential anesthesia codes for the procedure. Check documentation such as the excision location to determine the best-fitting anesthesia code. 
 
Pay special attention to documentation for cases that usually have multiple anesthesia code choices, such as:

• Abdominal procedures (upper versus lower abdomen)
 
• Arteriovenous (AV) grafts and fistulas

• Neck dissections (radical, modified radical, etc.)
 
• Heart cases (use of pump oxygenator, hypothermic circulatory arrest, or separately reimbursable services such as transesophageal echocardiography [TEE], Swan-Ganz or central venous line placement or Doppler studies)
 
• Thoracoscopies (use of one-lung ventilation)

• Procedures on extremities (upper arm versus forearm).

3. Follow Codes to the RVG

Use the ASA’s Relative Value Guide (RVG) to confirm that your Crosswalk code selection is correct or to narrow your choices when the Crosswalk lists alternative anesthesia codes for the procedure. The RVG also lists the current base unit values for anesthesia and pain management services.

Remember: If more than one anesthesia code applies to the procedure, choose the one with the highest base value. For example, the surgeon may perform a hysterectomy (00840, Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; not otherwise specified) with cholecystectomy (00790, Anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; not otherwise specified). You’ll report 00790 for the procedure because it has a higher base value than 00840 (7 base units versus 6 base units).
 
“When both Crosswalk code options equally reflect documentation and there is no difference in base units, I choose to use the default code,” Mullins says. When in doubt, get more documentation to base your decision on.

4. Narrow Your Options

 “Some of the biggest Crosswalk problems are naturally from the procedure codes that have multiple anesthesia codes,” Johnson says, “but another problem is with procedures that don’t list the anesthesia code you want to use.”
 
Johnson and Mullins agree that one such procedure is direct creation of a dialysis AV fistula of the upper arm. The anesthesia code (01844, Anesthesia for vascular shunt, or shunt revision, any type [e.g., dialysis]) falls under the Forearm, Hand and Wrist category of CPT’s anesthesia section. “Some of these AV fistulas are placed in the thigh or upper arm,” Johnson says. “So people question which code to use.”
 
Example: The next time you’re in this situation, consider this walk-through example from Mullins:

 • The CPT code is 36821 (Arteriovenous anasto-mosis, open; direct), which only has a Crosswalk selection of 01844.
 
• If the procedure you’re coding includes AV fistula placement somewhere other than the forearm, hand or wrist, you may decide that 01844 is not appropriate.
 
• You might consider reporting 01770 (Anesthesia for procedures on arteries of upper arm and elbow; not otherwise specified) instead. But don’t miss the parenthetical note below the descriptor in your RVG: For dialysis access procedures, see 01844.
 
• Now do you agree with selecting 01770? Because of the note below 01770, you’re sent back to the original Crosswalk option of 01844.
 
Bottom line: In this scenario, you thought 01844 didn’t make sense for the procedure. After further evaluation, you saw that the RVG directs you to this code, but it still does not accurately reflect the anatomic location. “That’s why you should remember that the RVG is just a guide,” Mullins says. “You must use your best judgment in deciding whether to follow the RVG’s guidance or choose the anatomically correct code.”

5. Use Your Best Judgment

Although the Crosswalk and RVG help you select the best anesthesia codes for services, remember that they are guides …quot; not absolutes.
 
“It is important to recognize that the listing of a CPT-4 code with an anesthesia CPT-4 code does not limit or restrict use of an alternate or unlisted anesthesia code,” states the Crosswalk’s introduction (2006 Crosswalk, page v).
 
“You must analyze all documentation and use your best judgment,” Mullins says. When you need further research, Mullins recommends that you refer to official sources of the payers, government entities, professional societies and others.
 
Final advice: “The three books (CPT, ASA Crosswalk and ASA RVG) are intended to be used together for coding anesthesia-related services,” Mullins adds. “They are coding companions. Exclusive use of one book alone can result in incorrect coding.”