Anesthesia Coding Alert

Tired of submitting medical necessity letters to support providing anesthesia to a patient who couldn't tolerate sedation? ICD-9 2010 answers your prayers while providing stage-specific codes for gout and giving  individual codes for irritability and two buckle fractures.

You know the drill: A gastroenterologist wants your anesthesiologist to provide anesthesia for a patient undergoing a colonoscopy because the patient has had a previously failed moderate sedation session. Now, you've got to explain the circumstances so that the insurer will cover the anesthesia.

Time-saver: With ICD-9 2010, you'll have a specific code that paints this picture. New code V15.80 (Personal history of failed moderate sedation) will "support the medical necessity for an anesthesiologist to provide anesthesia services rather than moderate sedation which didn't work in the past," explains Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, of MJH Consulting in Denver. Code V15.80 could justify the presence and payment of anesthesia services after conscious sedation failed, says Scott Groudine, MD, professor of anesthesiology at Albany Medical Center in New York. "Now the anesthesiologist has a tool to say, 'I am here because the surgeon tried and could not do it!'"

Example: In the above colonoscopy scenario, you'd report the colonoscopy anesthesia diagnosis first, followed by the personal history code. "V15.80 will probably be justification to pay for anesthesia services for a colonoscopy under most plans," Groudine says.

The surgeon who performed the original procedure in which the moderate sedation was not effective would use new code 995.24 (Failed moderate sedation during procedure). Going forward, this patient will have a history of failed moderate sedation.

Rheumatoid arthritis, multiple arthritis, and occasionally gout can be an indication for total joint replacement. If your physician lists gout as a reason for total joint replacement, make sure you're up to date on the changes to 274.0 (Gouty arthropathy).

When insurers require the new ICD-9 2010 codes, you'll need a fifth digit on 274.0 (Gouty arthropathy). ICD-9-CM 2009 does not distinguish between the different conditions (acute or chronic) and presence or absence of tophi. To indicate the condition's stage, choose the fifth digit using the terms in the chart below.

The progression of gout is from acute gout to chronic gout. For newly diagnosed patients with acute symptoms of gout, assign 274.01 (Acute gouty arthropathy). For patients with a history of recurrent attacks of acute gout with or without tophi, report 274.02 (Chronic gouty arthropathy without mention of tophus [tophi]). If tophi are mentioned without specifying the site, use 274.03 (Chronic gouty arthropathy with tophus [tophi]).

Watch out: If documentation specifies tophi to the ear or the heart, the old ICD-9 codes still apply:

• 274.81 -- Gouty tophi of ear

• 274.82 -- Gouty tophi of heart.

Example: A 40-year-old male complains of recurring tenderness of the big toe associated with a prominent bony lesion in the same area. The appropriate code for this situation is 274.03.

Are the changes making you feel nervous and irritable? You'll soon be able to code each of those symptoms separately. "ICD-9 2010 also creates new codes for irritability (799.22) and impulsiveness (799.23), and requires a fifth digit on the code for nervousness (799.21 from 799.2)," says Donna J. Walaszek, CCS-P, in Northampton, Mass.

Code 799.2 (which becomes invalid as of Oct. 1) "historically represented irritability and nervousness," says Walaszek. "New codes in 2010, 799.21 (nervousness), 799.22 (irritability) and 799.23 (impulsiveness), provide a more definitive representation for these presenting signs and symptoms."

ICD-9 2010 will bring you two new torus fracture options: 813.46 (Torus fracture of ulna [alone]) and 813.47 (Torus fracture of radius and ulna)."These types of fractures usually involve pediatric patients, and the treatment options may be different for these types of fractures," says Lynn M. Anderanin, CPC, CPC-I, COSC, senior coding consultant for Health Info Services in Park Ridge, Ill.

"Torus" fractures are sometimes called "buckle" fractures, and they are stable and nondisplaced. What happens is the topmost layer of bone on one side is slightly compressed.

"Medical necessity of these treatments would be justified by the diagnosis," says Anderanin. Use 813.46 for only the ulna, or 813.47 for fracture of both bones.

Be careful: You shouldn't confuse these codes with the existing torus fracture code 813.45 (Torus fracture of radius) and other radius and ulnar fracture codes specified in the 813.xx (Fracture of radius and ulna) range.