Anesthesia Coding Alert

"Be sure the consultation has the proper documentation to support it," says Jann Lienhard, CPC, a New Jersey coding consultant. "Also be sure the physician's chart notes are up to speed for the level of consultation being performed."

Code it: If documentation supports a consult - and if billing a consult is appropriate according to your group's guidelines - you'll probably report 99251 (Initial inpatient consultation for a new or established patient, which requires these three key components: a problem-focused history; a problem-focused examination; and straightforward medical decision making ... Usually, the presenting problem[s] are self-limited or minor. Physicians typically spend 20 minutes at the bedside and on the patient's hospital floor or unit). 

Codes CPT 99252-CPT 99255 are other options in this series, so report whichever service the documentation supports, says Julee Shiley, CPC, a South Carolina coding consultant.

Diagnosis: Also check that the patient's diagnosis meets medical-necessity criteria for a consult. The most common diagnosis supporting an epi blood patch is post dural puncture headache (or PDPH) (349.0, Reaction to spinal or lumbar puncture).
 
PDPH is a well-recognized complication of dural puncture, whether the puncture is accidental or intentional (medical journals report 80 percent of patients complain of headache following dural puncture). Most headaches occur on the first day following dural puncture. Shiley says that headache (784.0) is another frequent diagnosis for the consultation if the case does not involve PDPH.
 
Factor 2: Pinpoint the Anesthesiologist's Role

Anesthesiologists administer many blood patches for spinal taps performed by neurologists or emergency physicians. If your physician administered anesthesia during the procedure and knows the patient, he doesn't need to perform a consult to determine whether the patient has a spinal headache to justify the epidural patch (he's already done it as part of the anesthesia workup prior to the procedure).

Extra step: If your anesthesiologist was not involved with the original procedure, then performing a consult will help verify that the patient does have a spinal headache and will benefit from the blood patch. The physician must complete a thorough history and evaluation to ensure he is treating a spinal headache instead of another problem such as a cerebral aneurysm.

Factor 3: Decide if the Epi Patch Is Billable

Some coders recommend that you report the blood patch (62273, Injection, epidural, of blood or clot patch) but say you should not charge separately for the consult/visit. They reason that skipping the consult charge is a public-relations matter, especially if your physician performed the service that caused the headache. (Public relations aside, you also obviously won't charge a consult if the documentation doesn't support all the criteria.)

"This is truly a 'situation-specific' issue because both codes may be appropriate, depending on the circumstances," Shiley says. "Just be sure the documentation and medical necessity support whatever service you report."

Note: See "Test Yourself" below for examples of situations when our experts say you should - and shouldn't - charge separately for the blood patch.

Factor 4: Check for Other Management

Epidural blood patch placement is a well-recognized and effective therapy for spinal headaches, but it's not normally the first treatment option.
 
Most spinal headaches should be managed medically first, which means it's unlikely that the physician would administer an epi blood patch on the same day as the original procedure.

First-line management for the headache can include strict bed rest, hydration to increase cerebral spinal fluid pressure, drinking caffeinated beverages, and administering analgesics. In rare instances, the physician might perform epidural saline injections. It usually takes 1-5 days to medically manage a spinal headache.

But you will sometimes have cases in which the anesthesiologist performs the epidural patch on the same day as the anesthesia procedure. In this situation, append modifier -59 (Distinct procedural service) to the blood patch code 62273.

Shiley also recommends submitting the claim with the medical record.

Caution: Before coding for the epi patch and original procedure, realize you may have a problem with carriers (such as some Medicaids) that will not pay for more than one service per day.

The bottom line: Many coding guidelines are black and white, but there are shades of gray for you to consider in each situation. This scenario is a great example of how several coding options are correct, depending on the circumstances.

"It may be that you would only charge the consult when a more extensive workup is needed to determine whether the blood patch is necessary, or if the anesthesiologist determines that a blood patch is not needed," Shiley says. "We find that we often bill the blood patch alone or the consult alone - we rarely bill both together."