Anesthesia Coding Alert

Hint: Focus on the medical -- not the dental -- payer.

Many patients have separate medical and dental insurance, which can raise questions when it's time to file your anesthesiologist's claim. Focus on the medical side and learn payer guidelines, however, and you'll avoid the potential double-billing trap.

Focus on Single Charge for Two Insurances

Coders know how to handle claims when patients have primary and secondary coverage with two insurance companies, but that's not the same as having separate medical and dental insurance.

Remember: Dental insurance is the channel for dentists to file their claims.

"Dental insurance takes one set of codes that are not conducive to anesthesia, and medical insurance takes another set of codes," explains Cindy Smith, CPC, with Professional Healthcare Billing Services in Charleston, W.V.

Result: You'll only report the anesthesia provider's service to the medical insurance company, not the dental insurer.

Use the Right Modifier with 00170

Unless the patient has major surgery, most dental procedures requiring anesthesia will lead you to 00170 (Anesthesia for intraoral procedures, including biopsy; not otherwise specified). Calculate the total minutes for the procedure and append appropriate modifiers for the anesthesiologist's or CRNA's professional portion. Options could include:

• Modifier AA -- Anesthesia services performed personally by anesthesiologist
• Modifier QK -- Medical direction of two, three, or four concurrent anesthesia procedures involving qualified anesthesia professionals
• Modifier QX -- CRNA service: with medical direction by a physician
• Modifier QY -- Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist
• Modifier QZ -- CRNA service: without medical direction by a physician.

Assess the Best Diagnosis Options

Two typical diagnosis for anesthesia during dental cases are 520.6 (Disturbances in tooth eruption) or 521.00 (Unspecified dental caries). Check the other options under code family 521.0x (Dental caries), however, to ensure you choose the most appropriate code.

Next, select a secondary diagnosis code supporting the medical necessity of performing the procedure under anesthesia. Conditions such as mentally challenged patients (317-319), autism (299.0), or a history of other combative or disorderly conduct during a previous dental encounter (300.00, Anxiety state, unspecified) could all help justify separate anesthesia services.

"When billing to Medicaid, we also include modifier EP (Service provided as part of Medicaid early periodic screening diagnosis and treatment [EPSDT] program) on our claim," says Teresa Celestino, CPC, PCS, with Tejas Anesthesia in San Antonio, Tx.

Caveat: Know the guidelines for your payers and states before filing claims. "Medicare will not pay for any dental in the states that I code for (Oklahoma and Arkansas), even with underlying medical conditions," says Tanya Beaven, CPC, CMC, PCS, ACS-AN, anesthesia coder with Medical Management Professionals in Tulsa, Ok.

Remember Referrals for Success

Watching details before and after providing care can make a difference in claims success.

Referral: "We bill for a CRNA practice in Louisiana that does quite a few 'dental restorations' on children as young as one year old," says Davieda Skobel, CLPN, CPC, coding manager for Engage Healthcare Business Services in Columbus, Ohio. "We always have a referral from their primary care physician -- it's a must."

"Most Medicaid carriers pay dental for children, but not for adults," Skobel adds. "Almost all these patients are with Louisiana Medicaid. We don't get paid much, but we do get paid."

Details: Another "must" is ensuring the biller has all the necessary information. "We had a situation where the billing company did not get copies of the cards," Smith says. "They couldn't see where the claims went and didn't have numbers to call to see exactly what was covered and how it was covered. It was a difficult process."

Appeals: Celestino says they sometimes have to appeal the claim with a letter of medical necessity from the dental provider. "If the patient's medical insurance doesn't cover any type of dental procedures, we collect our portion prior to the procedure," she says.

"We send paper claims with operative reports on first submission to medical insurance since many claims are denied without it," adds Vanessa Campbell, CPC, with Niagara Frontier Billing in New York. "Maybe a short cover letter indicating the patient's young age and the number of teeth being treated along with the operative report would cut down on the number of denials."

Change Tactics for Hospital Billing

If you also bill for the hospital where the dental procedure took place, you'll submit additional codes.

The facility claim should include 41899 (Unlisted procedure, dentoalveolar structures) as well as the appropriate codes for medications and supplies. Bill the patient's health insurance for the services.

Exception: In rare instances, the commercial payer might request that the hospital submit a dental code instead of 41899 or another CPT® code to represent the facility fee portion. Complete the claim as the payer requests, but you'll still only file with the patient's medical/health insurer --" not the patient's dental plan.