Anesthesia Coding Alert

For many specialties, coding and billing office visits and consultations are routine. For an anesthesiology practice, the fees for the same or similar E/M services are often bundled with the overall procedure or included in a global period, making coding a bit more complicated. The majority of surgical procedures listed in CPT include a global period the time before, during, and a specific number of days after the procedure that is part of the primary surgical fee. Therefore, anesthesiologists cannot regularly charge separately for the preoperative evaluation, anesthesia during surgery, or the follow-up visit. But, dont lose hope there are times when anesthesia providers can charge separately for these services. Asking the right questions in the right order can get you on the correct coding path.

Is Service Included in Global Period?

Some anesthesiology procedures (which are starred) have zero global days, so anesthesiologists can bill separately for them. CPT says, Certain relatively small surgical services involve readily identifiable surgical procedures but include variable preoperative and postoperative services (i.e., incision and drainage of an abscess, injection of a tendon sheath, manipulation of a joint under anesthesia, dilation of a urethra). Because of the indefinite pre- and postoperative services, the usual package concept for surgical services cannot be applied.

Anesthesiologists can also bill separately for non-starred procedures that have no global period (zero global days), including injections and other pain-management procedures. This is because theyre not services that are within the global anesthesia fee of a consultation or outpatient visit. For example, an epidural steroid block (62311) has zero global days, so it can be billed as a separate procedure along with the appropriate-level consultation or outpatient visit code. The E/M code should be appended with modifier -25 (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to indicate the E/M was separate from the block.

Is It an Outpatient Visit or a Consultation?

Before coding a visit, youll need to determine whether the time with the patient is an office visit or a consult, and that depends on the way the primary care or other physician refers the patient. If the referring physician requests the anesthesiologist to evaluate and treat a patient, the patients care is now in the hands of the anesthesiologist. This is an office visit. If a physician asks the anesthesiologist to render an opinion or give advice about the patients condition, its a consultation. Following are examples of both:

Outpatient Visit: An orthopedic surgeon refers a patient with low back pain to an anesthesiologist. Because other pain management is not an option, the surgeon thinks an epidural might help the patient. The anesthesiologist examines the patient, administers an epidural steroid block, then sets an appointment for follow-up in two weeks.

Because the anesthesiologist assumed care of the patient for this problem and planned follow-up, it is not necessary to send a report to the surgeon before billing. The practice would code the visit 99201-99205 (office or other outpatient visit for the evaluation and management of a new patient), append modifier -25, then add the code for the epidural (64479-64484, depending on the site). As always with modifier -25, provide strong documentation to justify the separate billing. If the patient returns another day for the epidural, you could not append modifier -25 to the treatment code.

Consultation: A surgeon sends to the anesthesiologist a potential transplant patient who must be approved for anesthesia to qualify for the donor list. The anesthesiologist examines the patient and subsequently files a full report with the surgeon. The patient does not see the anesthesiologist until surgery. This is a consultation, billed with 99241 through 99245, depending on the level of the service, because the surgeon requested the examination and a report.

A consultation can include diagnostic or therapeutic services at the same or subsequent visits, which can be billed in addition to the consult code. For example, during a consult, the anesthesiologist might perform a diagnostic lumbar puncture (62270*). Code this visit with the appropriate E/M consultation code to which you append modifier -25 and bill separately for 62270*.

An initial consultation can also lead to additional visits if the pain-management specialist reports findings to the referring physician and recommends further treatment.

Which Is the Best E/M Code?

Once a patient visit qualifies for separate E/M coding, you determine the level of services provided so you can select the most appropriate code, says Susan Callaway, CPC, CCS-P, an independent coding consultant in North Augusta, S.C.

Office visit codes are grouped according to where the service takes place and whether the patient is new or established (99201-99215 for office or other outpatient visits for new or established patients; 99241-99245 for office or outpatient consultations for new or established patients; and 99251-99255 for initial outpatient consultations for new or established patients). Determining the type of visit leads you to the correct E/M section, and the complexity of the history and physical and medical decision-making dictates which code to use.

More Modifiers

In addition to modifier -25, anesthesiologists frequently have to use two other modifiers to describe more fully their services and the circumstances in which theyre provided.

Modifier -57 (decision for surgery): Append this modifier to the E/M office or consultation code if the primary care physician has decided to perform surgery to correct the problem.

Modifier -53 (discontinued procedure): Append this modifier if the anesthesiologist performs a standard preoperative workup, but the procedure is cancelled and rescheduled. If the rescheduled date is far enough in the future to merit another complete pre-op consult (usually at least two or three weeks later), the original exam an be billed using the appropriate E/M code along with modifier -53. The second consult is included in the global fee for the anesthesia service at the time of the surgery.

Understanding global days and having clear documentation of whether time with a patient qualifies as an office visit or consultation help reflect provider services more accurately, says Linda Thompson, office manager for the anesthesia and pain management practice Westside Anesthesia in Wichita, Kan. Get as much documentation related to the case as possible, be familiar with your local carriers guidelines, and work with them to understand their criteria for reimbursing anesthesia E/M services, she advises.