Anesthesia Coding Alert

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

Many dental procedures don't require the services of an anesthesiologist because the dentist handles the pain relief. But your anesthesia provider can be called in on occasion, so be sure you know how these cases are like any others you code - and how they differ.

Focus on Medical Insurance, Not Dental

If the patient has both medical and dental insurance, less experienced coders might assume you file according to the dental plan. That's not the case, however.

Here's why: Dental insurance is how dentists file their claims, not how you report the associated anesthesia. Dental insurance codes focus on procedures that don't normally require full-blown anesthesia.

Medical insurance uses another set of codes that includes anesthesia services. As an anesthesia coder, you'll report your provider's service only to the medical insurer, not the dental.

Bottom line: Having separate medical and dental insurance is not the same as having primary and secondary insurance coverage with two different companies.

Choose the Correct Performance Modifier

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 appendthe appropriate modifier(s) 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 K00.6 (Disturbances in tooth eruption) or K02.9 (Unspecified dental caries). Check the other options under code family K02 (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 (F70-F79), autism (F84.0), or a history of other combative or disorderly conduct during a previous dental encounter (Z86.5X) or (F41.9, Anxiety, 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 Kelly D. Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Fla.

Caveat: Know the guidelines for your payers and states before filing claims. For example, Medicare will not pay for any dental in some states, even if thepatient has underlying medical conditions that could help justify anesthesia use.

Referrals Can Lead to Reimbursement Success

Watching details before and after providing care can make a difference in claims success. For example, many Medicaid carriers will cover dental anesthesia for children even though they won't for adults - if the child has been referred by their primary care physician. Even if your anesthesia provider doesn't get paid much, something is better than nothing.

Details: Coders say 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, you can try to collect your portion prior to the procedure.

Another tip: Send paper claims with operative reports on first submission to medical insurance since many claims are denied without it. A short cover letter indicating the patient's young age and the number of teeth being treated along with the operative report could possibly 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.