Anesthesia Coding Alert

A common pain-management trend is to allow patients to control the amount of analgesia they receive after certain procedures. This is particularly true for surgical or obstetrical patients, and sometimes even pediatric patients. Its a service that has been used for a number of years, but anesthesia coders say its becoming more and more popular. In many instances, reimbursement for patient-controlled analgesia (PCA) is being denied. To determine whether to spend the time filing for reimbursement, know your carriers policies and the terms of your contracts.

Proponents of PCA say it allows patients to have more control of their situation, and provides a more accurate medication dosage since only the patient knows when or how much pain he or she is in. The patient pushes a button to deliver a measured amount of medication intravenously. The physician prescribes a maximum dose for a particular time period, so the patient cannot administer more medication than the physician would recommend.

Deciding Whether to File

With more physicians agreeing with the concept and many patients responding favorably to it, the question for anesthesia coders is whether they should attempt to be reimbursed for PCA once its been administered or count it as a loss and write it off up front.

Medicare will not reimburse for PCA in any way, says Scott Groudine, MD, chair of the government, legal and economics affairs committee of the New York State Anesthesia Society. Reimbursement can really be hit or miss, at least in New York. Some of our local HMOs will reimburse for one or two days of follow-up PCA after a procedure, but that depends on the contract we have with them.

Reimbursement for PCA should always be considered when youre negotiating contracts with different carriers, advises Dana Goodridge, director of operations at Comprehensive Medical Management, a Newport, Ky., firm that specializes in medical billing. We work with clients across the country, and several national carriers such as Aetna/US Healthcare, Humana, Cigna, United Healthcare and Anthem will usually reimburse for PCA. Medicaid will reimburse in some states but not in others, so its important to know what your local policy is. For other carriers, review your contracts and ask specific questions about whether PCA is covered.

If You Decide to File

PCA charges are entered separately from the professional fee for the service. The best way to code for this reimbursement depends on how the anesthesia group handles the service. Some practices or hospitals have a designated acute pain service team that handles all PCA follow-up care. In this case, PCA services are billed at a different time and on a different claim form from the original anesthesia. Therefore, it is just a one-line item on the claim form.

Coding for PCA can vary, depending on whether the carrier wants CPT codes or anesthesia codes, says Goodridge. She gives this example of how the care could possibly be coded:

Mrs. Smith has an inpatient total abdominal hysterectomy done on Dec. 8, 1999. PCA is started following the surgery, and two days of PCA follow-up care and maintenance are allowed. The coding for each day of care could be:

*58150: Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s).

**99251: Initial inpatient consultation for a new or established patient, which requires a problem-focused history, a problem-focused examination and straightforward decision-making.

***99231: Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: a problem-focused interval history, a problem-focused examination and medical decision-making that is straightforward or of low complexity.

+00840: Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; not otherwise specified.

++01997: Daily hospital management of intravenous patient-controlled analgesia. If this code isnt accepted by your carrier, bill the service with 99231.

If the patient in this example had an epidural catheter, the follow-up would be coded with 01996 (daily management of epidural or subarachnoid drug
administration).

Do You Need Modifiers?

Groudine and Goodridge are not aware of any carriers that typically want PCA treatment filed with a modifier. However, Goodridge does say that you may need to include a modifier when billing for post-op pain epidurals. Kristen Adams, assistant administrator of anesthesiology at Weill Medical College of Cornell University, agrees. If you file for a pain management epidural on the same day as surgery, be sure to include modifier -59 (distinct procedural service), she says.

If You Decide Not to File

Although PCA is popular among patients and physicians alike, many anesthesia groups choose to not file for reimbursement. Reimbursement can vary by carrier, and may not be at a high enough level to merit the staff time necessary.

Deciding whether filing for PCA is worth it depends on how much time your staff has to track reimbursements and follow up on accounts, says Groudine. It may not be worth the effort if you routinely get denials from your major carriers.

Adams and Goodridge both say that being familiar with your contracts and knowing which carriers will reimburse for PCA is important. Knowing your carriers and the terms of your contracts lets your office staff spend their time on billing cases and resubmitting denied claims more efficiently, Goodridge says.

You can always file with the carriers you know will pay and write off the others without even trying to get reimbursed, Adams adds. Be sure your collections staff knows which carriers will reimburse and have them follow up with those carriers to be sure you get whatever money you should. Dont waste time trying to get reimbursed by plans that dont usually do it.

Adams also points out that the physician should document that he or she is providing PCA even if no reimbursement is expected. Its vital that your physicians document the amount of uncompensated or free care theyre providing, especially in a teaching facility, she says. It also helps track the physicians productivity level and can help you decide if its worth continuing to offer.

Offering PCA can really boost patient satisfaction for your practice and the hospital, she continues. You need to weigh the level of patient satisfaction and goodwill against the business side of it. If its not cost effective for your group to do, try to find other ways to make it work.

Adams and Goodridge suggest these alternative ways to offer PCA when its not cost effective for the anesthesia group to handle alone.

1. Train a nurse on the hospitals staff or a CRNA in the anesthesia group to administer and oversee PCA instead of the physician doing it. If lots of the hospitals patients have PCA, lobby for the hospital to employ a PCA specialist, Adams says.

2. Spread the educational responsibility among other qualified staff. Even if other staff members are not allowed to administer PCA, they can help teach the patients about the service and answer basic questions.

3. If a physician must administer PCA, be sure thats all he or she is doing when seeing the patient. Let other staff handle issues as appropriate so you get your moneys worth out of the anesthesiologist while he or she is there.

Medicare says that post-op pain relief is included in the surgeons global fee, Groudine adds. Rather than have the anesthesiologist pay for a CRNA to administer PCA, the surgeons could hire a pain provider with the appropriate credentials (RN, CRNA, PA) to manage their routine PCA care. After all, why should the anesthesiologist pay for a salary line when Medicare says that the service is being compensated through the surgical fee? Of course, an anesthesiologist or other expert should still handle any unusual PCA situations.

PCA has been around for a long time, and is getting more popular all the time, Adams says. Its used a lot on certain procedures such as kidney transplants or cardiothoracic bypass that tend to be part of package deals with insurance carriers. Know the types of procedures youre usually asked to order PCA for and which packages anesthesia is included with. That will help you decide if its best for your practice to offer the service and get reimbursed, expect to write it off, or work with the hospital to share the job with their staff.