Anesthesia Coding Alert

By Barbara Johnson, CPC, MPC
Consulting Editor

Anesthesia historically has been difficult to code and bill and still is. Issues such as inadequate information, improper use of diagnosis codes, and carriers who deny anesthesia services if the code does not match that of the associated procedure provided by the surgeon create the challenge. This article should help you guide anesthesiologists and CRNAs in providing the type of information you need to code correctly and receive appropriate reimbursement.

Inadequate Information

Very often, the diagnosis leading to the procedure that requires anesthesia is vague and incomplete. Abdominal pain (789.0X), pelvic pain (625.9) or tumor (239.X) might be the only information a coder receives. For example, a physicians notes might indicate elevated BP, but you cant code or bill elevated BP. The coder cannot possibly know whether the patient has hypertension (401.9) or just elevated blood pressure without documented hypertension (796.2). Similarly, many patients take Synthroid or Levoxyl, but their chart does not mention hypothyroidism (244.9). One of the best examples of incomplete information Ive ever seen was a transabdominal hysterectomy (58150) with a diagnosis of motion sickness (994.6).

Many other issues consistently present coding difficulties, including those below.

Pathology information. Because anesthesia professionals rarely have access to it, they should not change any notations of tumors, lesions or masses and simply code the diagnoses for their purposes as neoplasms of unspecified etiology. Even using the uncertain behavior codes with neoplasms is risky, because that implies the possibility of labeling the patient as having a malignant tumor. This makes it a permanent part of the medical record and/or chart, and could lead carriers to deny the patient insurance in the future.

Diabetes mellitus 250.XX is difficult to code. Anesthesia providers commonly use DM as a code abbreviation, but frequently dont provide additional information thats required for correct coding and matching reimbursement, such as Type I (insulin dependent) or Type II (non-insulin dependent), controlled or uncontrolled. Diabetes complications, such as neuropathy, nephropathy and retinopathy all common problems that require a different approach to coding frequently suffer from the insufficient chart information syndrome.

See chart. Many physicians believe see chart is adequate information for the coding staff. The problem is that the majority of coders dont see the chart. Information about medications or something as simple as a hemoglobin count should always be included in the anesthesia record for coding purposes. The hemoglobin count can provide the kind of information that allows staff to code a condition more accurately and possibly provide an additional diagnosis for anemic patients. For instance, it can help clarify whether the anemia is due to blood loss (code 285.1 for acute, or 285.0 for chronic), is aplastic (284.9) with the many sub-diagnostic categories associated with it, pernicious (281.0) or simply unspecified (285.9).

Incorrect Primary Diagnoses

Anesthesiologists and CRNAs often fail to document current conditions, such as complication with or rejection of a transplanted organ, tumors including status and location, and frequently indicate leukemia without specifying the type and whether it is in remission. Instead, theyll list the diagnoses for providing anesthesia for angiograms, MRIs, CT scans, radiation therapy and other tests or treatments as S/P (status post or surgical procedure) and H/O (history of). Unfortunately, many of the ICD-9 codes for these diagnoses cannot be used as the primary diagnosis.

Look for V Code Clues

Including V codes (supplementary classification of factors influencing health status and contact with health services) in a diagnosis can help coders answer many questions. These codes, often considered backup rather than primary diagnoses, can sometimes serve as the primary diagnosis. For example, if a patient has a disease that requires medical care or treatment, V codes for services such as dialysis or chemotherapy can be the primary diagnosis with supporting documentation of the reason for treatment.

However, you cannot use a V code for a primary diagnosis when the patient has a history of certain diseases, has had organ transplants or joint and heart valve replacements, and has a family history of disease.

Most ICD-9 manuals indicate that these codes should not be used as primary diagnosis codes and, consequently, carriers might deny them so youll have to take a different coding approach. A good example would be a patient seeking breast reconstruction following mastectomy. V45.71 (acquired absence of breast) is not a primary diagnosis; neither is V10.3 (malignant neoplasm of the breast).

The coder knows the insurance carrier will pay for reconstruction, but how should the reconstruction be coded to indicate that it is not cosmetic surgery? Many practices have billed code V51 (aftercare involving the use of plastic surgery, following healed injury or operation) as a primary diagnosis. But, even though its legal and ethical, many carriers consider the procedure cosmetic rather than reconstructive surgery.

The most important thing coding professionals can do is help anesthesia providers understand the type of information that must be in the chart for coding purposes. Providing an accurate diagnosis and complete, detailed information medications, lab results, a brief history of the patients condition is the only way to justify anesthesia for a procedure and select the most accurate and appropriate codes for the situation.