Anesthesia Coding Alert

Supporting medical necessity and checking policies help clear the way.

If your anesthesiologist provides care during endoscopic gastrointestinal procedures, you don't have many codes to memorize. Paying attention to those choices and the best supporting diagnoses, however, will help smooth your gastro claims every time.

Start With the Correct Crosswalk Choices

CPT® divides anesthesia codes for endoscopic gastrointestinal procedures by "upper" and "lower." Your three primary choices are:

• 00740 -- Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum (for EGD, or esophagogastroduodenoscopy)
• 00790 -- Anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; not otherwise specified (for laparoscopy)
• 00810 -- Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum (for colonoscopy).

"We bill MAC anesthesia on our upper endoscopies and colonoscopies," says Kristie Brown, account specialist with Gastroenterology Associates of Pensacola in Florida. "There are only two anesthesia codes that we bill out for: 00740 and 00810."

Modify it: When coding for monitored anesthesia care (MAC), remember to include MAC modifiers as needed. For Medicare patients, append modifier QS (Monitored anesthesia care service) to the procedure code. You might also need to report modifier G9 (Monitored anesthesia care for patient who has history of severe cardio-pulmonary condition), depending on the patient's medical history.

Dig Deeper for Diagnosis Supporting Medical Necessity

Payers look for diagnoses that justify administering anesthesia during EGDs or other gastro procedures. Your claim should include a diagnosis that indicates a co-existing medical condition that supports the anesthesiologist's involvement, not just the gastrointestinal condition leading to the procedure.

Potential diagnoses could include:

• Parkinson's disease (332.0)
• Heart conditions (such as 410.xx, Acute myocardial infarction or 427.41, Ventricular fibrillation)
• Mental subnormality or retardation (318.x)
• Seizure disorders (such as 780.39, Other convulsions)
• Anxiety (such as 300.0x, Anxiety states).

You might also be able to submit a diagnosis for failed sedation attempts: 995.24 (Failed moderate sedation during procedure) or V15.80 (Personal history of failed moderate sedation).

"Billing for endoscopic and GI procedures remains fluid," says Kelly Dennis, MBA, ACS-AN, CAN-PC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Fl. "Make certain you understand specific payer policies regarding separate anesthesia services for these procedures."

"Specific diagnosis codes for failed moderate sedation or a history of failed sedation (such as V15.80) are welcome additions," Dennis adds. "The challenge is to make certain documentation supports using the codes. Notes in the pre-anesthesia or pre-operative assessment should indicate the patient's situation."

Narrow Multiple Procedure Options to a Single Code

The gastroenterologist might perform more than one procedure during the encounter, but that doesn't mean you submit multiple anesthesia codes.

Guideline: CPT®'s anesthesia guidelines for separate or multiple procedures instruct you to report the "most complex" procedure. The American Society of Anesthesiologists recommends you bill the "anesthesia code with the highest base unit value." Both resources, however, direct you to report the combined (or total) time for all procedures with a single anesthesia code.

Example: The physician completes an EGD and colonoscopy during a single session. Your anesthesiologist documents a combined start/end time of 60 minutes. Because codes 00740 and 00810 each have the same base value of 5, you can submit either code with the total amount of time. Be sure the reported diagnosis code matches the reported procedure code.

Code 00790 carries a base unit value of 7. If the physician completes an upper intraperitoneal procedure or laparoscopy during the same encounter as an EGD or colonoscopy, you'll submit 00790 with the combined total time for both procedures.

Don't Let Payer Guideline Changes Throw You

Different payers might have different guidelines for MAC during endoscopic procedures, so do your homework before filing claims. "We researched and contacted each individual insurance carrier to get their billing and reimbursement guidelines," Brown says.

"A claim denied by one carrier might be processed smoothly by a different carrier," says Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the AMA's CPT®'s Advisory Panel. "The policy for anesthesia coverage and payment methodology is not standardized amongst Medicare intermediaries or non-Medicare carriers."

Bottom line: Periodically check your payers' policies to ensure coverage status hasn't changed. The time you spend confirming details now will pay off with easier claims processing later.