Anesthesia Coding Alert

Anesthesia care is often finished once the patient officially transfers from the care of operating room staff to the postanesthesia care unit (PACU) staff. But sometimes anesthesia care is still needed in special situations. A patient may be moved from PACU to the intensive care unit (ICU) because of an irregular heartbeat, respiratory failure, drug-induced coma, other complications of surgery or other unusual circumstances. Since billing for anesthesia is not normally needed in these circumstances, getting reimbursed can be frustrating and tricky. But coding professionals and care providers can obtain appropriate reimbursement with good documentation, patience and a good working relationship with the carrier.

Why Is Anesthesia Coding Difficult?

Many people in the field believe that anesthesia coding is more difficult than for other specialties because of the way the system is structured. Does the carrier want surgical codes or anesthesia codes? Do you use codes from the ASA Crosswalk even if they are not included in CPT Codes, or stick with CPT-sanctioned codes? Which code do you use to figure base units when several different procedures are performed under the same anesthesia administration? The questions go on and on, and the answers which can be tricky in any situation get even trickier when the patient being treated is in ICU.

Coding for anesthesia in ICU is very difficult, says Cindy Lane, a coder in the anesthesia department of Vanderbilt University in Nashville, Tenn. Information about it is very hard to find. I spend a lot of time consulting with other people trying to find out what others do and how well it works.

When May ICU Care Be Necessary?

Separate anesthesia billing should be the exception, rather than the rule, for ICU patients, says Leisa Gonnella, anesthesia administrator at the University of Virginia in Charlottesville, Va. The surgeon is paid to do routine post-operative care, she explains, and we have been told that routine can include care in the ICU. But there are certain situations when anesthesia care is merited for ICU patients.

Anesthesia providers may assist in transferring patients who are on ventilators and need vasoactive drips from PACU to ICU. Billing for this service can be awkward because patients are often taken for x-rays and other studies by nursing staff and respiratory therapists instead of by anesthesia staff. If the patient is monitored and vital signs are recorded on the anesthesia record during transportation, this time could be billed as discontinuous anesthesia time.

Many anesthesia providers usually work with ICU patients when they are on a ventilator or need arterial lines or central venous catheters placed. The provider may also have to intubate the patient because of respiratory failure or cardiac arrest (or some other reason), or occasionally insert a Swan-Ganz catheter. These situations may be billed as separate anesthesia services.

Remember that anesthesiologists have expertise in monitoring, which often includes line and catheter placement. And although starting these types of lines in difficult patients is commonly referred to as anesthesia, the placement may not be a separate anesthesia service. An anesthesia service is defined as providing pain relief, anesthesia or sedation while someone else performs a surgical procedure. If placing a CVP, code the procedure using the appropriate surgical codes if the anesthesiologist performs the service.

Coding anesthesia service for CVP would imply that I gave sedation while someone else (the surgeon) did the procedure, explains Scott Groudine, MD, associate professor of anesthesiology at Albany State University in Albany, Ga. If I place the line, then I did the surgery, and the service needs to be coded appropriately.

Groudine recommends 93503 for the Swan-Ganz catheter insertion, 36620 for arterial-line placement, and 36489 for CVP for pressure or feeding.

Careful Documentation Gets ICU Claims Paid

Some anesthesia coders say insurance carriers always seem to deny claims for their groups ICU services. The carriers often say the charges are incidental to the original procedure. Trying to make the carrier see that the ICU charges are separate from the original charge can be very frustrating.

Gonnella offers this tip for practitioners attempting to be reimbursed for ICU services: document, document, document. It is imperative to document the medical necessity of the anesthesiologists care. If possible, get the surgeons request for your help with this patients care in writing.

Critical care services, 99291 (critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and 99292 (critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes) can be billed more easily now than an evaluation and management (E/M) code, she adds, but, again, watch the documentation. And remember that if you bill for critical care service you dont bill for separate procedures. Weve found that billing for critical care across the board from Medicaid to commercial carriers is better than billing for the E/M service and procedure separately.

If documentation does not support filing with critical care or E/M codes, Gonnella advises billing only for the applicable procedure when the attending physician is involved in the case.

An Illinois anesthesia group often gets ICU denials for 36489* (placement of central venous catheter [subclavian, jugular or other vein] [e.g., for central venous pressure, hyperalimentation, hemodialysis or chemotherapy]; percutaneous, over age 2) and 36620 (arterial catheterization or cannulation for sampling, monitoring or transfusion [separate procedure]; percutaneous). Recently the group has been sending appeal letters that include verbiage supporting their position to their insurance carriers to try to get reimbursement.

One explanation in a letter reads, Insertion of arterial line: This procedure is needed where blood loss, control of blood pressure or possible major complications is an issue. This procedure is used only when necessary, realizing possible risks of the procedure. Based on the American Society of Anesthesiologists Relative Value Guide, this procedure is separate from the surgical procedure and therefore is not incidental.

The explanation in a letter regarding insertion of a CVP line reads, This procedure is used for infusion of large volumes of blood and fluids to sustain adequate blood pressure while monitoring the volume status of the patient. This procedure is used only when necessary, realizing possible risks of the procedure. Based on the American Society of Anesthesiologists Relative Value Guide, this procedure is separate from the surgical procedure and therefore is not incidental.

If procedures such as line placements or catheter insertions are coded as anesthesia services, I am not likely to be paid, Groudine says. If I bill them as a surgical service, I dictate an operative note and include that note when the insurance company is billed. When an operative note accompanies the bill, there is rarely a problem with getting paid.

Lane adds that her coding staff is also looking for better ways to make ICU reimbursement easier. Its mainly a networking effort for me, she says. I talk to as many people as I can, find out what has worked or not worked for them, and decide on the best course of action based on their experiences.