Anesthesia Coding Alert

Procedure details determine if you can report them separately

Remembering a little-used modifier could be your key to getting paid for wake-up tests, but not all experts agree.

The scenario: The anesthesiologist induces a patient before halo application. After the procedure, he turns the patient prone and performs a wake-up test to ensure the patient isn't paralyzed. Satisfied with the results, he administers general anesthesia to put the patient back to sleep so the surgeon can complete the procedure.
The coding question: Can you report the wake-up test in addition to the anesthesia?

This question is difficult to answer because some details are missing (it was posted on our listserv this way). But adding hypothetical details helps you evaluate the best way to handle the case.

Verify the Type of Procedure

Your first step in deciding how to handle the situation is to verify the type of surgery performed.

Administering a wake-up test is common practice during spinal surgeries, according to Tonia Raley, CPC, claims processing manager for Medical Information Systems in Phoenix. If the procedure in question is spinal surgery, the extra service of a wake-up test is already included in the increased base values for anesthesia.

Example: Anesthesiologists often perform a wake-up test during spinal instrumentation procedures (such as 22840, Posterior non-segmental instrumentation [e.g., Harrington rod technique, pedicle fixation across one interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation]).

Code 22840 crosses to anesthesia code 00670 (Anesthesia for extensive spine and spinal cord procedures [e.g., spinal instrumentation or vascular procedures]). Anesthesia codes for spinal procedures have high base units to reflect the cases- level of difficulty (such as 13 base units for 00670). If the anesthesiologist administers a wake-up test during spinal procedures, the anesthesia code units already compensate for the service.

Although you won't charge extra for the wake-up test in these situations, you-ll still consider it when completing your claim.
 
-You bill the total anesthesia time in addition to the procedure's base units, not only the -asleep- time,- says Julee Shiley, CPC, CCS-P, CMC, a South Carolina coding consultant. -Even if you don't charge separately for the wake-up test, you-ll have extra reimbursement associated with additional time unit(s) due to more extensive service.-

Shiley and Raley say a wake-up test generally takes 30 minutes or less. That might not seem like much time, but every unit counts when you-re filing claims.

Halo note: You must also consider the halo application mentioned above. Although halo applications often go hand-in-hand with cervical spinal procedures, the surgeon could apply a halo for facial procedures such as maxillofacial reconstruction (21100, Application of halo type appliance for maxillofacial fixation, includes removal [separate procedure]).

How you handle reporting the wake-up test will probably remain the same, considering that coders such as Shiley and Raley believe the test is part of the anesthesia service. Just be sure to report anesthesia code 00190 (Anesthesia for procedures on facial bones or skull; not otherwise specified) for facial procedures instead of a spinal anesthesia code.

Know Your Carrier Guidelines   

Whether you-re able to report the wake-up test separately can also depend on your carrier.

Some carriers will allow you to report 00630 (Anesthesia for procedures in lumbar region; not otherwise specified) or 00670 (Anesthesia for extensive spine and spinal cord procedures [e.g., spinal instrumentation or vascular procedures]) for a wake-up test, with modifier 22 (Unusual procedural services).

Document details: If your carrier falls in this camp, remember to include any documentation explaining why the extra service was -greater than required.- Appropriate documentation includes the surgeon's request for a wake-up test, documentation of all procedures being performed, patient risks and possible complications, and the reasons for the procedures.

Code with caution: Even if the carrier will allow you to code the wake-up test separately with modifier 22, some coders still don't feel comfortable reporting the service that way.
 
-We use modifier 22 very rarely, if ever,- Shiley says. -We would most likely select 00670 for extensive spine and spinal cord procedures, and if this code is selected, we would not use modifier 22. The wake-up test does not add additional risk and does not take an inordinate amount of time, so I would not use modifier 22 even if ASA codes 00600, 00620 and 00630 were used.-
 
Other coders agree that although carriers will occasionally pay modifier 22 after appeal, most allow only 10-25 percent of payment. Their advice: Make sure your payment increase will be worth the work to obtain the additional payment. 

Wake-up Tests May Be Moving Out

As procedures and techniques evolve, codes change or disappear accordingly. Raley and some other coders expect this to be the case with wake-up tests.

With evoked potentials tests expanding, today's wake-up tests could eventually phase out except in specialized cases. Instead of reporting a wake-up test, the code for a motor evoked potentials test comes from 95925-95927 (Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system) and 95928-95929 (Central motor evoked potential study [transcranial motor stimulation]).

-These tests identify potential compromise to the patient's central nervous system during certain surgical procedures, such as brain and spinal surgery,- Raley says. -The tests alert the surgeon and anesthesiologist if the surgical procedure, patient position or anesthesia may need to be altered to avoid permanent neurological damage to the patient.-

As an anesthesia coder, whether you report an evoked potentials test depends on the person administering it.

Neurologists or neuro techs often perform evoked potentials tests. But some carriers, such as Empire Medicare, allow other credentialed physicians to perform them. Part of Empire's policy states, -This test must be requested by the operating surgeon and the monitoring must be performed by a physician, other than: the operating surgeon, the technical/surgical assistant or the anesthesiologist rendering the anesthesia.-

Bottom line: If appropriately trained, a partner in the anesthesia group could bill for the service if he is credentialed and available to perform it. In that case, you-ll report the service with either 95928 or 95929.

The evoked potentials test typically provides the surgeon with enough information to continue the case without asking the anesthesiologist to perform a wake-up test. -It appears that unless there is an issue found during the evoked potentials testing, a wake-up test procedure will not be or is not necessary.- Shiley says.