Anesthesia Coding Alert

Laryngoscopies and bronchoscopies are performed fairly frequently, especially to diagnose respiratory ailments or clear newborns' airways. In some of these cases, an anesthesiologist might have to perform an intubation as a separate procedure or provide general anesthesia in conjunction with the laryngoscopy or bronchoscopy. However, under CPT anesthesia guidelines, laryngoscopy (31505-31579) and bronchoscopy (31622-31656) are bundled codes, which usually do not include administration of general anesthesia nor permit billing intubation as a separate procedure. The coder's challenge is to know when to bill intubation as a separate charge, when general anesthesia services are covered for these two procedures, and which codes, modifiers and documentation to append.

 

Billing Intubation as a Stand-alone Procedure

 

Securing an airway, or intubation, integral to routine anesthesia administration, is considered a part of the global anesthesia procedure and, therefore, not separately billable. However, if an anesthesiologist intubates a patient for laryngoscopy or bronchoscopy and provides no additional services, virtually all carriers allow billing the procedure separately. For example, if an anesthesiologist performs fiberoptic intubation for a direct laryngoscopy, and it is not part of the anesthetic, it should be covered if you submit it with surgical code 31575 (laryngoscopy, flexible fiberoptic; diagnostic) and appropriate documentation, such as an operative note. 

Cecelia McWhorter, CPC, anesthesia coder with Comp One Services Ltd. in Oklahoma City, suggests using code 31599 (unlisted procedure, larynx) appended with modifier -22 (unusual procedural services) for certain situations. Some commercial carriers pay for fiberoptic intubation for laryngoscopy and bronchoscopy by anesthesiologists in cases that require special skill, perhaps on patients with a difficult history of the procedure or who are morbidly obese," she says. 

Intubations performed in surgical and postsurgical emergencies, even though they might not be associated with a laryngoscopy or bronchoscopy, are usually covered. According to Medicare guidelines, if intubation takes place in the operating suite as part of standard monitoring, the procedure is not separately billable because general anesthesia services include the preparation and monitoring. However, intubation for a rapidly deteriorating patient who will require mechanical ventilation can be billed separately with CPT 31500 (intubation, endotracheal, emergency procedure). Documentation accompanying the claim must include medical necessity, the patient's history and physical status, progress notes and operative record. If the emergency intubation is noted as "stat" or "emergent," use 518.82 (acute respiratory distress/insufficiency) or 518.81 (acute respiratory failure) as the diagnosis, depending on the main symptoms the anesthesiologist documents in the patient's chart. 

McWhorter says an anesthesiologist could be summoned to reintbate a post-op patient who suddenly stops breathing. "Appropriate coding for this case is 31500 appended with modifier -59 (distinct procedural service) if the same pain management specialist who provided anesthesia services during the patient's earlier surgery performed the emergency intubation. The modifier signals the payer that the post-op procedure was separate from the surgical intubation." Tonia Raley, CPC, the claims- processing team leader for Medical Information Management Systems in Phoenix, a billing firm specializing in anesthesiology claims, recommends using modifier -59 or -76 (repeat procedure by same physician) to ensure that the insurance company won't bundle the code. "Coders should also have an additional diagnosis on the claim to support the medical necessity of the reintubation. It should be different from the ICD-9 code that was used to justify the original surgical procedure and its accompanying anesthesia," she adds.

 

Beyond Intubation

 

In some cases, an anesthesiologist might have to provide more than intubation for laryngoscopy and bronchoscopy, particularly if medical necessity requires that the patient be fully sedated. For example, while general anesthesia is not routinely administered for flexible fiberoptic laryngoscopy, if the surgeon uses a rigid laryngoscope, general anesthesia is appropriate. If the surgeon performs the procedure and the anesthesiologist provides the anesthesia care, you can bill separately for it. Raley suggests using the appropriate ASA code with base, time and identifying modifiers, including the CPT surgical code. She provides two scenarios: 

 

If a surgeon performs a direct laryngoscopy for removal of a foreign body, the anesthesiologist bills with CPT code 31530 (laryngoscopy, direct, operative, with foreign body removal) and ASA code 00320 (anesthesia for all procedures on esophagus, thyroid, larynx, trachea and lymphatic system of neck; not otherwise specified), which has a value of six base units plus time. 

 

If a surgeon performs a bronchoscopy for removal of a foreign body, the anesthesiologist uses CPT code 31635 (bronchoscopy [rigid or flexible]; with removal of foreign body) and ASA code 00520 (anesthesia for closed chest procedures; [including bronchoscopy and pericardial window] not otherwise specified), which has a value of six base units plus time.

Scott Groudine, MD, an anesthesiologist in Albany, N.Y., recommends that coders ask their carries if it is necessary to include both a CPT and an ASA code. He further states, "Local medical review policies (LMRPs) often determine the rules for payment and the definition of medical necessity for anesthesia services during laryngoscopy and bronchoscopy in Medicare patients. Some carriers pay for anesthesiology; others list conditions and require supporting documentation to justify the need for anesthesia services."

Many local Medicare carriers reimburse for the anesthesia performed in conjunction with laryngoscopy and bronchoscopy if the procedures are performed in these facilities. However, linking the procedure codes with a correct ICD-9 diagnosis code is insufficient for payment. Diagnosis or clinical suspicion must be documented and support the medical necessity of the procedure or Medicare will assume it was for screening and deny the claim. 

In addition, all ICD-9 codes must be coded to the highest level of specificity. For anesthesia for an open wound to the neck, for example, a specific diagnosis code would be 874.1 (larynx and trachea, complicated [open wound to the larynx; with major infection, delayed treatment or healing, tissue loss, or with foreign body]) rather than the more general 874.0 (larynx and trachea, without mention of complication). Administration of anesthesia (by an anesthesiologist or CRNA) for bronchoscopy is also payable under Medicare when a patient is unstable (ASA class four or five), confused, in extreme pain, unable to remain completely immobile, combative or extremely anxious, or has any other problem that would compromise the procedure.

Groudine and Raley suggest that coders always check with their local Medicare carriers and private insurers before submitting claims in order to determine their processing policies.