Anesthesia Coding Alert

The third code related to CABG, 00560 (Anesthesia for procedures on heart, pericardial sac, and great vessels of chest; without pump oxygenator), does not apply to these cases because the physician already needs the oxygenator to achieve deliberate hypothermia and will also need it to normalize the patient's body temperature.

Qualifying-circumstances code +99116 (Anesthesia complicated by utilization of total body hypothermia [list separately in addition to code for primary anesthesia procedure]) is the additional code that some carriers will allow you to bill when reporting hypothermia. If allowed, it can be billed along with either 00562 or 00563 for an additional five base units.

However, some physicians opt not to bill the additional units for 00562 or 00563 even if it is allowed; they feel that adding units without specific justification is an invitation to an audit. And some carriers deem the billing of 99116 and 00563 simultaneously to be redundant (because 00563's descriptor includes hypothermia) and forbid it.

"Code 99116 specifies deliberate hypothermia used in conjunction with any anesthetic," says Abraham Rivera, MD, CEO of Pain Management Medical Group in Albany, N.Y. "It is specifically useful for brain surgery where even mild hypothermia has been proven beneficial, but I don't see the rationale for adding this code when 00563 is used. With code 00562 you can argue that the patient needed hypothermia for a specific reason, such as brain or myocardial protection because of poor cerebral or myocardial blood flow. In that case, adding 99116 would be reasonable."

Rivera sums up the distinctions between the codes: 00562 is used when the patient is on the cardiopulmonary bypass (CPB) machine and hypothermia is not used; coding and reimbursement should not present problems.

Code 00562 in conjunction with 99116 is for cases of CPB plus hypothermia used for cardioprotection or brain protection; this is the typical CABG case, and carriers should reimburse for it if you document an identifiable reason for hypothermia.

Code 00563 reports a case of total circulatory arrest, such as in cases of aortic arch replacement or transposition of great vessels; CPB was used to achieve hypothermia and rewarming, but the case had a period of circulatory arrest (legal death).

"The question of billing hypothermia to Medicare is answered quite simply," says Joanne Mehmert, CPC, CORT, a professional coder with the consulting firm Auditing and Compliance Education Inc., in Leawood, Kan. "Medicare does not pay any modifying units." This is because Medicare considers code 99116 to be included in the codes for other services, as mentioned above.

But some commercial carriers, such as Blue Cross/ Blue Shield for Virginia and North Carolina, will pay for code 99116 with CABG, says Judy Wilson, CPC, business administrator with Anesthesia Specialists, a physician group in Virginia Beach, Va., that focuses on cardiac cases. "Medicare doesn't pay for hypothermia, but most commercial carriers do," she says. "Ninety percent of our CABG patients have hypothermia, and we bill the correct CPT code (such as 33512, Coronary artery bypass, vein only; three coronary venous grafts) with 99116. Some carriers request the anesthesia record for payment. As long as it's documented in the anesthesia record, we don't usually have any problems with reimbursement for hypothermia."

Two other examples of procedures Wilson sees in conjunction with code 99116 are 93505 (Endomyocardial biopsy) and 36489* (Placement of central venous catheter [subclavian, jugular, or other vein] [e.g., for central venous pressure, hyperalimentation, hemodialysis, or chemotherapy]; percutaneous, over age 2).

Code +99100 (Anesthesia for patient of extreme age, under one year and over seventy [list separately in addition to code for primary anesthesia procedure]) and qualifying-circumstances codes and modifiers such as -26 (Professional component) and -59 (Distinct procedural service) can be coded in conjunction with 99116 as appropriate.

For example, +99140 (Anesthesia complicated by emergency conditions [specify] [list separately in addition to code for primary anesthesia procedure]) could be used with 99116 if hypothermia is induced with a craniotomy for a patient under age 1 or over age 70. An appropriate time to use modifiers is when the anesthesiologist places an epidural for postoperative pain management (in which case you would append modifier -59), but these situations are not very common with CABG cases.

Medicare reimbursement for code 00563 varies by area. Some carriers will not accept 00563 in these cases because they include total hypothermia in code 00562. But some coders, including Wilson, say their Medicare carrier does accept 00563. If your carrier will accept it, use it when appropriate instead of 00562 because you'll be reporting the procedure more accurately and will be reimbursed for a 25-unit procedure instead of a 20-unit procedure.

Rivera, Mehmert and Wilson agree that one of the most important things you can do when coding for cases with hypothermia is to have supporting documentation for the claim.

"Documentation would include notes on why hypothermia is medically necessary and the temperature line across the anesthesia record that is truly 'hypothermia,' " Mehmert explains. "There are degrees of hypothermia, and if a physician is charging extra for hypothermia we would look for a larger difference than simply a degree or two below normal."

"The physician needs to actually write in the patient's anesthesia record and the operative report that hypothermia was achieved, rather than just let it be assumed from other information in the patient's record," Wilson adds. "Use correct codes and modifiers when needed, and send the anesthesia record with the bill. I feel that if the physicians bill for the case based on documentation, they're fine. If it's not documented, then don't bill for it."

Rivera agrees. "Try to make your 99116 stick out as a truly identifiable deviation from the norm," he says. "A simple entry on the anesthesia chart stating 'Hypothermia used for cardioprotection' can go a long way."

What if the carrier rejects your claim for hypothermia reimbursement as not medically necessary, even with all the documentation in place? Wilson sends the carrier another copy of the anesthesia record along with information stating that inducing hypothermia is the norm for CABG cases. "A growing trend might be performing CABG without hypothermia, but most cases don't go that way," she says. "You have to have an ideal patient in order to perform CABG without hypothermia, and only 1 percent to 2 percent of the patients fit into that category because of other factors."

"The challenge with 99116 is that the code was created to reimburse for a specific, identifiable use of hypothermia outside the usual course of an anesthetic," Rivera says. "Hypothermia is the norm with CABG surgery, so the carrier can argue that hypothermia is included in the typical performance of the operation. The burden is on the physician to prove that hypothermia was specific to the case and not generically used across the board for all these cases."