Anesthesia Coding Alert

Hint: Pay special attention to throacoscopy, spine, and cardiac cases.

Anesthesia coders automatically turn to their provider's notes and the anesthesia record for details regarding cases. But the surgeon's record can also contain information that can make or break your claim, such as case complexity or procedure changes.

Dig Into the Case Complexity

"There are two things we identify most often when comparing the anesthesia documentation to the operative note," says Cindy Hinton, CPC, CCP, CHCC, owner of Advanced Coding Solutions in Franklin, Tenn. "Number one is that we find that the procedure was more complex than expected."

Example: The anesthesia record includes a notation of "knee arthroscopy." The operative note states that the surgeon completed debridement, repair, or reconstruction. Knowing that the surgeon performed something more than a diagnostic procedure can move you from reporting a code such as 01382 (Anesthesia for diagnostic arthroscopic procedures of knee joint) to 01400 (Anesthesia for open or surgical arthroscopic procedures on knee joint; not otherwise specified). The change from 01382 to 01400 means you're entitled to report 4 base units instead of 3.

"The code series has diagnostic codes that often lead into surgical/therapeutic codes, depending on what is actually performed once the surgeon gets in there," Hinton says. "That's why there can be confusion."

Don't Miss Thoracoscopy Differences

CPT® 2012 added several new codes for thoracoscopy (32666-32674), making those procedures tougher to report correctly, unless you study the documentation.

Example: It's common to find notes such as "thoracoscopy with wedge" documented in the patient chart. The confusion lies in knowing which type of wedge the note refers to since some wedge resections are diagnostic and others are therapeutic.

"Typically, the surgeon will specifically call it a diagnostic or therapeutic wedge when he describes the indication and intended procedure," Hinton says. "So, rather than trying to interpret, look for the surgeon to classify it."

Result: "A diagnostic thoracoscopy may result in 11 base units for the anesthesiologist, and a therapeutic in 15," Hinton adds. "It's important to properly classify the procedure so you can avoid over- or under-billing."

Be Alert to Spine and Cardiac Details

Several other procedures tend to harbor extra units that you might find in additional documentation. Consider these common scenarios from Sharon Donelli, CPC, CPMA, administrative officer and director of coding and compliance for Integrated Physicians Management Services in East Hartford, Conn.

• Spinal cases when the surgeon uses instrumentation as part of his or her technique, or if the spinal procedure includes multiple levels. Using spinal instrumentation results in 5 additional units for the anesthesiologist during lumbar cases because you can report 00670 (Anesthesia for extensive spine and spinal cord procedures [e.g., spinal instrumentation or vascular procedures]) at 13 units instead of 00630 (Anesthesia for procedures in lumbar region; not otherwise specified) at 8 units. You also gain 3 additional units for thoracic cases when you report 00670 instead of 00620 (Anesthesia for procedures on thoracic spine and cord; not otherwise specified). "Anesthesiologists often leave this detail off the anesthesia record procedure description," Donelli states.
• CABG (coronary artery bypass graft) procedures performed off pump instead of on pump. You'll earn 7 additional base units for cases without the pump (25 units for 00566 [Anesthesia for direct coronary artery bypass grafting; without pump oxygenator] instead of 18 units for 00567 [Anesthesia for direct coronary artery bypass grafting; with pump oxygenator]).
• Circulatory arrest performed during a CABG case qualifies for 5 extra units (a total of 25) when you can submit 00563 (Anesthesia for procedures on heart, pericardial sac, and great vessels of chest; with pump oxygenator with hypothermic circulatory arrest ).

"Ideally, the anesthesia record will stand alone on its documentation, eliminating the need to investigate operative reports and other available sources," Donelli says. "However, when it's not possible for them to be privy to the details that drive additional charge opportunities, accessing operative notes can provide a lot of clarity."

Final tip: Keep copies of the operative notes on hand as part of your defense and to help justify your coding in the event of an audit.