Anesthesia Coding Alert

When the surgeon asks your physician to provide anesthesia during endoscopy, the first step toward receiving payment is proving medical necessity.

"If there are no known conditions that justify an anesthesia professional's involvement, the carrier may not consider it to be medically necessary," Shiley says. However, if the surgeon requests anesthesia administration because of known conditions that require additional monitoring, Shiley says it is reasonable - and wise - to charge separately for the anesthesia.
 
Conditions that help justify anesthesia's use because of additional monitoring include:

Medical-necessity policies are carrier-specific and can even vary according to the patient's current health. A carrier might list multiple diagnoses that warrant anesthesia for endoscopy but includes the stipulation that the condition must be active. For example, a history of asthma is not enough; the patient must be bothered by the asthma at the time of the endoscopy to justify anesthesia.

Tip: The patient's physical status indicator tells a lot about his condition. If the anesthesiologist assigns the patient a physical status of P3 (Patient with severe systemic disease) or higher, the patient probably requires additional monitoring. However, Medicare and some other carriers do not recognize physical status modifiers, so verify the carrier's guidelines before relying on these to justify anesthesia. CPT's anesthesia section includes complete descriptors and more information about physical status modifiers.

"The biggest challenge in many cases is meeting the medical-necessity criteria outlined by my carrier policies," says Samantha Mullins, CPC, MCS-P, manager of coding and compliance for VitalMed Inc. in Birmingham, Ala. She advises coders to create a template pre-anesthesia/anesthesia record for anesthesia providers that helps them remember to document the patient's underlying diseases or comorbidity. "The patient often has the medical necessity," she says. "It's just not documented appropriately."

"It is sometimes challenging when there is no additional documentation regarding why the procedure required anesthesia services," Shiley adds. "We don't have much to base appeals on for those cases."

Tip: If you still have problems with inadequate documentation, Shiley suggests gaining access to the patient's pre-op paperwork before coding the case. Information in the history and physical (H&P) might support why the surgeon requested anesthesia for a typical "conscious sedation" procedure.

Know the Carrier's Policy

Check the carrier's policies regarding endoscopy reimbursement so you can follow the correct guidelines.

Example: Palmetto GBA in South Carolina states that procedures such as discovery and excision of cononic polyps, evaluation of unexplained GI bleeding and diagnosis and control of hemorrhage indicate medical necessity for lower GI endoscopy. The same policy lists a number of noncovered contraindications that coders should be aware of before reporting procedures.

Medicare does not have an endoscopy policy, so local Medicare carriers are able to establish their own. Some Medicare carriers cover endoscopy with modifier -G8 (Monitored anesthesia care [MAC] for deep complex, complicated, or markedly invasive surgical procedures) along with an appropriate cardiovascular diagnosis (such as congestive cardiomyopathy [425.4] or chronic myocardial ischemia [414.8]).

Carriers that accept physical status modifiers might also require a patient status of P3 or higher before reimbursing for anesthesia.

A carrier's endoscopy policy might rule out reimbursement even if you show medical necessity. Example: Shiley's physicians administered anesthesia for a screening procedure on a patient who had a personal history of malignancy and post-op complications. The patient's history helped justify medical necessity, but the screening was not within the recommended timeframe of the state's LMRP. Medicare denied the initial claim and Shiley's appeal.

Report the Correct Code

If everything adds up to justify reporting the anesthesia, be sure to report the correct procedure code. 
 
Shiley and Mullins say most GI endoscopy cases fall under one of two codes:

The most common GI endoscopy procedures are colonoscopies and esophagogastroeduodenoscopies (EGD). Report 00810 for a colonoscopy and 00740 for an EGD. Both procedures can be either diagnostic or surgical (such as for removal of a polyp).

Codes 00740 and 00810 might be the most frequently used codes for these cases, but don't overlook a third anesthesia code that comes into play with some GI endoscopies: 00902 (Anesthesia for; anorectal procedure).

Double-Check NCCI Edits

The quarterly National Correct Coding Initiative (NCCI) edits often bundle anesthesia codes with a wide range of surgical procedures. Some edits in 2003 affected your coding of anesthesia and endoscopy, when NCCI listed anesthesia code 00740 as a component of several endoscopic procedures.

The same set of NCCI edits also established anesthesia code 00810 as a component of procedures 43201 (Esophagoscopy, rigid or flexible; with directed submucosal injection[s], any substance) and 43236 (Upper gastrointestinal endoscopy including esophagus, stomach and either the duodenum and/or jejunum as appropriate; with directed submucosal injection[s], any substance). That means you can't report anesthesia along with these services.

The Bottom Line

Many coders report seeing a trend in office, outpatient hospital and ASC locations having more anesthesia involvement in these types of cases.

"We're not doing an inordinate amount of these procedures, but they are increasing," Shiley says. "We're also having more inquiries from GI physicians about whether we would perform these cases if they moved to the outpatient hospital setting versus an endoscopy suite in a private office."
 
If your group is also experiencing this trend, work with your providers to encourage thorough documentation of medical necessity and work with your carriers to follow their guidelines for endoscopic anesthesia coding.

"As coders, we don't have the expertise to determine whether the service is MAC or general," Mullins says. "Look to your providers to help you determine which it is."