Anesthesia Coding Alert

Anesthesia coders don't delve into CPT's E/M codes as often as other specialties because most anesthesia codes include the pre-op exam, anesthesia during the procedure, and a follow-up visit. But there are times when you can code consultations and patient visits in addition to the procedure's anesthesia. Follow our checklists to determine whether you're losing revenue by not coding these services.

Know if It's Billable in the First Place

All patients go through a pre-op evaluation, which is why it is part of the anesthesia fee. That's also why coding for pre-op consults is a gray area that many anesthesia coders shy away from. Answer these questions to decide whether pre-op care qualifies as a billable consult.
 

Is the service a "starred" procedure? You can separately report "starred" procedures, those CPT codes followed by an asterisk, from other services because they  include only the surgical service (instead of being associated with pre- or postoperative services) and have zero global days. Many procedures fall into this category, such as most somatic and sympathetic nerve injections for various sites and levels (64400-64415, 64417-64445, 64450 and 64505-64530). The anesthesiologist bills the starred procedure as a single service or in conjunction with other separate procedures.
 
If you report more than one code for the visit, append modifier -59 (Distinct procedural service) to the starred code to indicate that the service was not part of another procedure. Jann Lienhard, CPC, a New Jersey anesthesia and pain management coder, also says to verify the diagnosis. "Be sure to get the correct diagnosis and reason for the anesthesiologist's visit (such as a pain management injection), not the reason the patient is in the hospital bed (such as surgery)," she says.
 
When you're dealing with starred procedures, remember that Medicare doesn't recognize this CPT designation. Instead, Medicare differentiates between "major" and "minor" procedures. Major procedures have a 90-day global period and don't include the surgeon's initial consultation or evaluation to determine the need for surgery; because of this, you report modifier -57 (Decision for surgery) with the E/M code. Minor procedures have 0- to 10-day global periods and require that a "significant, separately identifiable service" be performed in addition to the main procedure before you can report an E/M code for it. In this case, you would append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code.
 

Is the service included in the global period? Anesthesia providers can also code separately for non-starred procedures that have no global period. These include injections and other pain management procedures that aren't within the global anesthesia fee of a consultation or outpatient visit.
 
For example, an epidural steroid block (62310, Injection, single [not via indwelling catheter], not including neurolytic substances, with or without contrast [for either localization or epidurography], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or subarachnoid; cervical or thoracic; or 62311, ... lumbar, sacral [caudal]) isn't a starred procedure but it has zero global days, so you can report it separately with the appropriate consultation or outpatient visit code. Again append modifier -25 to the E/M code to indicate that the E/M service and block were separately identifiable services. Keep in mind that a consulting physician can begin treatment but not take over care of the patient for that diagnosis, Lienhard says. You're dealing with a referral instead of a consult once the anesthesiologist becomes the treating physician.
 

What's the patient's condition? Justifying an anesthesia consult for a P1 (A normal healthy patient) or P2 (A patient with mild systemic disease) patient isn't easy unless you can document that the service was drastically different from the standard pre-op anesthesia exam and was medically necessary. It's somewhat easier to justify consults with patients classified as P3 (A patient with severe systemic disease) or higher. For example, a patient who recently had an MI (myocardial infarction) would receive a higher P classification. This would help justify the surgeon's request for an anesthesia consult to assess the timing of an upcoming operation, says Scott Groudine, MD, an anesthesiologist in Albany, N.Y.

Know if It's a Consult or Outpatient Visit

If the referring physician asks the anesthesiologist to evaluate and treat the patient, the patient's care is now in the hands of the anesthesiologist. This is an office visit and referral, not a consult. If the physician asks the anesthesiologist to render an opinion or give advice on the patient's care or condition but not treat the patient at this point, it's a consultation. Remember these three R's to help determine if the visit qualifies as a consultation:
 

The surgeon requests (in writing) that the anesthesiologist see the patient for a particular reason and offer an opinion about his or her care.
 

The anesthesiologist sees the patient and renders an opinion on the patient's current condition and care plan.
 

The anesthesiologist sends a written report to the surgeon outlining the patient encounter and his or her findings (or recommendations).

The Medicare Carriers Manual says you can code a consult if each of these steps is documented in the patient's record and the anesthesiologist has not assumed patient care (MCM 15506). Report it with the appropriate E/M code depending on the site of service and level of service provided (you have many options here, from office or inpatient consults to ICU and confirmatory consults).

The consulting physician can perform diagnostic or therapeutic services at the same or later visits, which you can report in addition to the consult code. For example, the physician may decide to perform a lumbar puncture to help diagnose the patient's problem. Report the lumbar puncture (62270*, Spinal puncture, lumbar, diagnostic) along with the appropriate E/M code appended with modifier -25 to differentiate the services.
 
An initial consultation can also lead to follow-up visits. This is especially true if a pain-management specialist reports his or her findings to the referring physician and recommends further treatment. Always report the initial consultation with the appropriate E/M code (99261-99263, 99231-99233 or 99212-99215).
 
Code follow-up visits as consults or regular patient visits, depending on the circumstances. Periodic follow-up care that occurs at some point after the recommended treatment plan is instituted (several days to weeks or months) can still qualify for the consultation codes. But if the anesthesiologist sees and treats the patient regularly, he's no longer consulting or simply offering an opinion. Report this care as inpatient or office visits (depending on the setting).
 
When you're still coding consults, remember that not all consults are performed in-house. "They can also occur in the office setting," Lienhard says. "Teach the physicians to document everything so you have all the information you need to correctly code the procedure and distinguish whether it was a consult or visit."
 
Follow these tips for distinguishing consults from referrals or visits:
 

Everything related to a consult must be in writing, from the original physician's request to the anesthesiologist's report of his or her findings and opinion. "Writing a note to the referring surgeon and making recommendations on treatment options that need to be considered before surgery can even be scheduled is more along the lines of a consult," Groudine says. However, he also says that before you code a consult, be sure the request is for more than seeing the patient and making recommendations before surgery. If that's all the surgeon wants, it's routine preoperative care and is included in the global anesthesia fee instead of qualifying as a separate consult.
 

A consulting physician can begin treatment but not take over the patient's care on any level. "He can treat under the umbrellas of the referring physician but cannot assume care of the patient," Groudine says. For example, an internal medicine physician sends Mrs. Brown to a pain-management specialist for a back-pain consultation. The specialist sees Mrs. Brown and determines that her pain is either caused by or needs to be treated in a way outside his normal scope of care. He sends a report to the originating physician stating his opinion and recommending that Mrs. Brown undergo further diagnostic tests before continuing treatment. The pain-management specialist didn't take over Mrs. Brown's treatment, so he's still acting in a consulting capacity.
 

The purpose of a referral is to hand over some part of the patient's care to the anesthesiologist. For example, an internal medicine physician might send Mr. Thomas to an anesthesiologist because of back pain. The anesthesiologist evaluates Mr. Thomas and begins a series of blocks or other procedures to treat the pain. Once the anesthesiologist begins treating Mr. Thomas regularly, it is a referral that you code as office visits.

Choose Your Modifiers Wisely

All modifiers help describe the physician's services and the circumstances more fully so records can be accurate and reimbursement can be appropriate. Anesthesiologists don't use modifier -57 (Decision for surgery) very often, but it sometimes comes into play when reporting consults.
 
Primary-care physicians use modifier -57 when they decide to perform major surgery to correct a patient's problem. An anesthesiologist only uses modifier -57 when he is acting as the surgeon, as in pain procedures, but even then you'll probably rarely use it.
 
"The only time I use modifier -57 is when the surgeon conducts the E/M visit followed up by surgery," Lienhard says. "I haven't seen a case with the anesthesiologist performing a consult then acting as the surgeon (at least not for a major procedure)." In the rare cases when it applies to anesthesia, append modifier -57 to the E/M or consult code.
 
"The biggest challenge I see with coding consults and visits is that many coders and physicians don't know the difference," Lienhard says. "The word 'referral' has become synonymous with insurance PPO/HMO paperwork instead of the coding term. The best thing you can do is educate your coders and doctors so they understand the differences and can code them correctly."