Anesthesia Coding Alert

Patients may receive anesthesia when undergoing certain diagnostic tests such as electrophysiological studies (EPS), magnetic resonance imaging (MRI) or endoscopies. However, Medicare and other carriers may deem the tests medically unnecessary or deny the anesthesia as elective. Many local medical review policies (LMRPs) state that diagnostic tests performed for screening purposes and the accompanying anesthesia are excluded from Medicare coverage. Therefore, the key to anesthesia reimbursement is knowing which procedures are covered, how to apply anesthesia codes, and which diagnosis codes and documentation support the medical necessity of the diagnostic tests and the anesthesia.

Electrophysiological Studies

According to LMRP for Cigna Healthcare, North Carolina's Medicare Part B carrier, EPS provides information about rhythm disturbances in the heart. The studies place catheter electrodes percutaneously and transluminally into the heart. The electrodes detect electrical activity within the heart and stimulate the atria or ventricles. These studies determine if a given therapy is controlling a patient's rhythm disturbances or identify if a patient is at risk for sudden cardiac death.
 
CPT Codes 2001 lists a number of codes associated with these studies. Emma LeGrand, CCS, coding supervisor with North Jersey Anesthesia Associates, P.C., a 53-physician practice in Florham Park, N.J., notes three common procedures:
 

  

CPT 93642 electrophysiologic evaluation of single or dual chamber pacing cardioverter-defibrillator (includes defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing and pacing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters)
 

 

 

 

CPT 93651 intracardiac catheter ablation of arrhythmogenic focus; for treatment of supraventricular tachycardia by ablation of fast or slow atrioventricular pathways, accessory atrioventricular connections or other atrial foci, singly or in combination
 

CPT 93652 ... for treatment of ventricular tachycardia.

 
The corresponding anesthesia code for these procedures is 00537 (anesthesia for cardiac electrophysiologic procedures including radiofrequency ablation), which carries a base value of 10 units plus time units," LeGrand says. Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, lead CPC trainer and consultant for A+ Medical Management & Education of Absecon, N.J., adds that the Coder's Desk Reference suggests using 00520 (anesthesia for closed chest procedures; [including bronchoscopy] not otherwise specified), which has a base value of six units plus time units. Jandroep and LeGrand advise coders to ask their carriers which anesthesia code is appropriate.
 
Barbara Johnson, CPC, MPC, professional coder, Loma Linda University Anesthesiology Medical Group Inc. of Loma Linda, Calif., reminds coders some carriers require the surgical code and the anesthesia code, while others may want just the anesthesia code. "In addition, the anesthesiologist can only bill one anesthesia code," Johnson says. "Pick the one with the highest number of base units, then add the number of time units necessary to complete the entire procedure(s)."
 
As with all covered services, the ICD-9 code must support medical necessity. LeGrand says that the LMRPs of her Medicare Part B carrier, Empire Medical Services, list a number of ICD-9 codes related to the circulatory system that support EPS medical necessity, including 410-411.1, 427.1-428.1 and 456.0-456.20.

Magnetic Resonance Imaging

Many magnetic-resonance-imaging procedures do not require the use of an anesthetic. However, under certain circumstances, such as those involving small children, the mentally handicapped or adults with psychiatric disturbances (such as claustrophobia), anesthesia may be necessary to perform MRI successfully.
 
LeGrand notes that in her practice, the MRI procedures performed frequently with anesthesia include imaging of the brain (70551-70553), pelvis (72195-72197), abdomen (74181-74183) and spine (72141-72158). "All of these radiologic CPT codes crosswalk with anesthesia code 01922 (anesthesia for non-invasive imaging or radiation therapy), which carries a base value of seven units plus time units," LeGrand says. An ICD-9 code, i.e., 318.1, severe mental retardation, must be included on the claim to explain the examination and the extraordinary need for anesthesia for MRI.
 
Johnson adds that while few pediatric patients have Medicare, any claim for unusual anesthesia accompanying MRI (regardless of the patient's age) should include a note from the radiologist or primary care physician as to the reason, along with modifier -23 (unusual anesthesia). "This will generally give you all the documentation you need," Johnson says.

Endoscopy

LeGrand says that endoscopic procedures performed frequently with anesthesia include:
 

43235 upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic with or without collection of specimen(s) by brushing or washing (separate procedure)

43239 with biopsy, single or multiple

45378 colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (separate procedure)

45380 with biopsy, single or multiple

45383 ... with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique.

Surgical codes 43235 and 43239 crosswalk with anesthesia code 00740 (anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum), with a base value of five units plus time units. The anesthesia crosswalk for surgical codes 45378, 45380 and 45383 is 00810 (anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum), which has a base value of five units plus time.
 
Medicare edits list a number of endoscopic procedures where anesthesia is not deemed medically necessary. One of these is colonoscopy. LeGrand notes, "After much debate, our local Medicare review committee has agreed to pay for Propofol administered intravenously during colonoscopy (V58.83). For payment, we are required to submit paper copies of claims with a copy of the anesthesia record."
 
Johnson says getting paid for anesthesiology with endoscopy is difficult. "Again, claims should include an appropriate ICD-9 code that justifies the presence of the anesthesiologist or the induction of anesthesia," she says. "These codes might include those for unstable angina (411.1), asthma (493.9), mental disorders (290.0-294.9), alcohol and drug dependence (303.00-305.92), and mental retardation (317-319). Also, watch your diagnosis codes. Be specific, demonstrating to the carrier that the procedure was performed in order to make a diagnosis and not conducted as a screening."

Coding for MAC and Conscious Sedation
 
 
Although general anesthesia is sometimes used for EPS, MRI and endoscopy, monitored anesthesia care (MAC) or conscious sedation is more common. If MAC is administered, Medicare carriers may require appending modifier -QS (monitored anesthesia care) and/or -G9 (monitored anesthesia care for patient who has history of severe cardio-pulmonary condition). Additional modifiers may be necessary to indicate if the anesthesiologist or another qualified individual personally performed the anesthesia service.
 
An article in the July 1998 CPT Assistant states, "Codes 99141 (sedation with or without analgesia [conscious sedation]; intravenous, intramuscular or inhalation) and 99142 ( oral, rectal and/or intranasal) are to be used by the physician performing the procedure and are not to be used by the anesthesiologist; his or her time would be reported using codes from the anesthesia section of the CPT."
 
While American Society of Anesthesiologists and American Academy of Pediatrics guidelines suggest the presence of an intravenous line for patients who receive sedation/analgesia, they are not mandatory for patients who receive their medications through nonintravenous routes. Sedation/analgesia does not require the placement of an intravenous catheter. If an anesthesiologist places a catheter and provides no other services, you can separately bill its placement, using the appropriate 36xxx surgical code. Some LMRPs suggest Medicare only covers starting an IV placed in one of the great vessels, i.e., femoral artery, jugular vein.
 
LeGrand says their practice has not had a problem with bundled EPS or endoscopy codes, but she recommends coders review their Correct Coding Initiative (CCI). "Most Medicare carriers will not bundle the anesthesia portion of the claim," LeGrand says. "LMRPs often state that anesthesiologists can bill for the total amount of time spent. Yet, it never hurts to check a reference like CCI or to call your local carrier. Also, review your Medicare web site. For commercial carriers, try to develop an alliance with your carrier representatives. Sometimes issues can be resolved over the phone."
 
LeGrand states her practice's anesthesiologists provide services regardless of reimbursement. "However, if the service is uncompensated, we work out an agreement with the patient," LeGrand says. "In the future, we may implement a consent form, such as an advance beneficiary notice (ABN) to help us recoup payment from the patient for uncovered services." If no acceptable ICD-9 code pertains to the patient care, modifier -GA (waiver of liability) may be appended to the anesthesia code. This signifies that a waiver (the ABN) has been signed and that the patient is aware that Medicare will deny the claim.