Anesthesia Coding Alert

Surgery equipment and procedures are changing so quickly that the CPT is not able to keep up with some of the advances. This leaves some procedures without a specific code for billing purposes. How does this affect anesthesiologists? Some insurance carriers do not accept an anesthesia code alone for the surgerythey want the CPT code for the actual surgery instead. But anesthesiologists can get reimbursed for procedures that lack codes by using the codes for similar procedures or using the unlisted procedure code.

Which tactic is used may depend on the carrier. Check with your local carrier for guidelines on how to handle these types of procedures, and whether they require surgical codes (as in the examples below) or anesthesia codes for the procedures performed.

Code as Close as You Can

One area that many coders believe is lacking in appropriate codes is arthroscopy, says Deborah K. Hecht, CCS-P, a coding specialist with Professional Anesthesia, an 11-member private-practice anesthesia group with 45 certified registered nurse anesthetists (CRNA) in Akron, Ohio. This is especially true for procedures that are being done on the hands and fingers, she says. These procedures are being done more and more often because they are easier than ever to do and the patients recover so much more quickly. But how do you code for them when theres nothing in CPT that really applies?

One example of this situation is a rotator cuff repair, Hecht continues. Were doing them arthroscopically, but theres not a CPT code specific to it. Code 23410 is for the repair of an acutely ruptured rotator cuff. Code 29819 is for arthroscopy of the shoulder with the removal of a loose or foreign body. Neither code exactly covers the situation.

In that type of scenario, coding professionals can either be correct to the procedure or to the codeyou cant be correct to both. Each case is often considered individually, and the procedure is filed based on which code seems to be a little more appropriate for what was done.

Hechts solution is to file with the closest matching code possible without exceeding the procedures worth. I try to put something as close as I can without going over the top, she explains. Sometimes well use a code thats fairly on target and add modifiers to help make it more accurate. Of course, anytime we use modifiers we include all the supporting documentation to show why they were necessary.

For example, Hecht says that a physician may perform an evaluation and management (E/M) service on a new or established patient (code 99245 or code 99255, depending on whether the service is inpatient or outpatient) that takes longer to complete than is standard. If so, she codes the E/M service and adds modifier -22 (unusual procedural services) along with documentation supporting the modifiers use. If the service takes less time than usual, such as when a surgical case is not as involved as anticipated, she files with the appropriate procedure code and modifier -52 (reduced services).

Another possible solution is to manually add information to the closest fitting code that helps make it more specific. Thats what Margie Fahy, CPC, a coder with Childrens Anesthesiology Associates in Philadelphia, a 38-member private corporation with nine CRNAs, does in special situations.

Some of the surgeons at Childrens Hospital of Philadelphia are performing some of the breakthrough fetal surgeries, says Fahy, whose group does all the anesthesia for all surgeries at Childrens Hospital of Philadelphia. Fetal surgery is such a new area of medicine that there are no codes for it. Its not a situation thats common for most coders, so it will probably be a while before CPT includes codes for it. The best solution weve found so far is to use the closest matching CPT code and add on fetus manually.

Fahy cites two examples of fetal procedures that are done without having corresponding codes:

- Placing a titanium clip on the fetus trachea when the diagnosis is a congenital diaphragmatic hernia (756.6). This clip stays in place until delivery and gives the lungs space to grow. Fahy uses procedure code 31750 (tracheoplasty; cervical) since there is no specific code for it.

- Operating for a condition called twin-twin transfusion, when there is direct vascular anastomosis (an interconnection of blood vessels) between the placental circulation of the twins. There is no procedure code for the operation to ligate the anastomosis. The procedure is often done with a laparoscope, so they use code 58578 (unlisted laparoscopy procedure, uterus), code 58579 (unlisted hysteroscopy procedure, uterus) or code 59898 (unlisted laparoscopy procedure, maternity care and delivery). They may also opt to use code 59100 (hysterotomy, abdominal) if the procedure is open.

Codes to Use When Nothing Is Close

When a similar code cannot be found, code the procedure as an open procedurecode 01999 (unlisted anesthesia procedure). Many coding professionals agree that it may not necessarily be the best solution, but sometimes its the only option available. Some hospitals or group practices also establish an internal system of modifiers to track more accurately the types of procedures they perform regularly (for example, they may add LP to the open procedure code to indicate laparoscopy).

I try not to use the unlisted code unless its absolutely necessary, Hecht says. Your reimbursement wont be as accurate since the carrier wont have a specific procedure to base it on. Chances are, whatever the anesthesiologist did was a higher level service than youre reimbursed for with the generic code, so your reimbursement will usually be lower than it could be.

Hecht adds that one possible advantage to using code 01999 is that if its used often enough for the same procedure, the people who establish CPT codes will hopefully take note and create codes for it. All we can do in the meantime is code procedures the best we know how, and hope those codes are better defined in future editions of CPT.