Anesthesia Coding Alert

Hint:  Pay more attention to companion services than DLT

Coders- opinions differ on whether you can bill separately for a double lumen tube. If you-re on the fence in these situations, consider the following situation and then read what some of our experts recommend.

Scenario: Our anesthesiologist documented general anesthesia and double lumen for a lung biopsy. The chart does not specify if the surgeon used an open approach or thoracoscopy. Should I report general anesthesia for the procedure and add on the double lumen tube?

Double-Check the Surgeon's Technique

Your first step in handling this claim is to verify the surgeon's technique. CPT has two main coding options for this type of procedure, so determine which is correct before attempting to report the anesthesia:

- 32602--Thoracoscopy, diagnostic (separate procedure); lungs and pleural space, with biopsy. You should base your coding on this if the surgeon used a closed approach. 

- 32095--Thoracotomy, limited, for biopsy of lung or pleura. Work from this code instead if the surgeon used an open approach.

Don't just crosswalk: But filing the claim isn't as simple as crosswalking to a single anesthesia code. You also need to look at the anesthesiologist's work to narrow your options.

Track Down One-Lung Ventilation Details

Inserting a double lumen tube allows the anesthesiologist to use one-lung ventilation (OLV) during the procedure. Although the scenario above doesn't specify whether the anesthesiologist used OLV during the procedure, he probably did--inserting a double lumen tube that's not used for OLV is rare.

The physician receives higher reimbursement when he uses OLV, primarily because of the level of work and risk involved with the case.

If the record shows that the patient was on OLV, you can report one of the higher-unit codes that rewards the additional work involved:

- 00529--Anesthesia for closed chest procedures; mediastinoscopy and diagnostic thoracoscopy utilizing one lung ventilation. This code represents a mediastinoscopy approach to biopsy when the anesthesiologist uses OLV. It's more involved than a standard mediastinoscopy approach but is much less than a thoracotomy. Report 00529 if the surgeon used a closed approach (32602) and the anesthesiologist used OLV.

- 00541-- Anesthesia for thoracotomy procedures involving lungs, pleura, diaphragm, and mediastinum (including surgical thoracoscopy); utilizing one lung ventilation. This code for thoracotomy using OLV is worth quite a bit more than 00529 (15 units versus 11). Report 00541 if the surgeon used an open approach (32095) and the anesthesiologist used OLV.

Caution: Do not bill for one-lung ventilation unless the anesthesia record or graph clearly shows that the lung was deflated and re-inflated.

-A double lumen tube is usually placed when OLV is expected to be initiated, but you can't report an anesthesia code describing one-lung ventilation unless you have specific notations that it happened,- explains Samantha Mullins, CPC, MCS-P, ACS-AN, manager of coding and compliance for VitalMed in Birmingham, Ala. -Look for -one-lung vent started,- -left lung down- or similar notes, not just the placement of the double lumen in anticipation of needing it.-

No OLV means different codes: If you find that the anesthesiologist did not use one-lung ventilation, you-ll report a different anesthesia code:

- 00540 (Anesthesia for thoracotomy procedures involving lungs, pleura, diaphragm, and mediastinum [including surgical thoracoscopy]; not otherwise specified) for a thoracotomy. The code is comprehensive enough to include a lung biopsy.

- 00522 (Anesthesia for closed chest procedures; needle biopsy of pleura) for a closed needle biopsy.

-Our physicians are involved with a lot of cardiovascular cases, and we very rarely see needle biopsies of the lung anymore,- says Tonia Raley, CPC, claims manager for Medical Information Management Solutions in Phoenix. Because of this, you probably won't report 00522 very often for scenarios such as the one that our example describes.

Answer the Double Lumen Question

Now that you-ve verified the surgeon's technique and know whether the anesthesiologist used OLV, the next question is: Can you also bill for the double lumen tube? Consider these facts when making your decision: 

- The one-lung ventilation codes (00529 and 00541) include the extra work involved for services such as double lumen tube insertion. However, this can depend on the procedure performed and the carrier involved.

- Some carriers will allow you to add modifier 22 (Unusual procedural services) to the procedure code when the physician documents the double lumen's medical necessity for this patient.

- You might be able to append modifier 22 in the unusual case of having a double lumen tube that's not used for OLV. The anesthesiologist might opt for this technique if he needs to isolate one lung from the other because of infection or if he needs to differentiate the ventilation of each lung in an intensive care unit (ICU). Example: The anesthesiologist places a double lumen tube to isolate or selectively ventilate an ICU patient's lungs. You could report 31500 (Intubation, endotracheal, emergency procedure) and append modifier 22 because he performs the intubation as a surgical service instead of as an anesthesia service.

- If you append modifier 22 for the double lumen, some carriers (such as Cigna Medicare in Idaho, North Carolina and Tennessee) require documentation when you file the claim. Other carriers don't require reports with the initial filing, but you must have documentation in the medical record if it's requested.

- Adding modifier 22 or reporting the double lumen tube might make your coding more complete (for carriers that allow the distinctions), but don't expect extra reimbursement. When the anesthesiologist places the double lumen in anticipation of one-lung ventilation, the time to place it is included in your overall time units.

Some Coders Dismiss Separate DLT Coding

Despite these potential go-aheads for separately billing the double lumen tube, many coders don't believe separate billing is appropriate.

-When our physicians started using one-lung ventilation before specific codes became available, we posed the question of how to bill for the service,- Raley says. -Now, however, we think it's pretty cut and dry. If OLV is documented, we have anesthesia codes to represent it and higher value units to include complexities such as double lumen tubes.-

Mullins agrees. -Double lumen is just a type of endotracheal tube,- she notes. -Intubations--regardless of the kind--are bundled into the anesthesia code.-

Bottom line: Check with your carrier to determine its policy on reporting double lumens to ensure you report the case correctly. Regardless of whether you report it separately, look at the other pieces of the puzzle--the surgeon's technique and the anesthesiologist's OLV use--to ensure you submit the correct anesthesia code.