Advanced Search

Anesthesia Coding Alert

Look at Who Does What If Youre Coding Anesthesia for Eye Surgery

Published on Sun Jun 01, 2003

Eye surgeries are some of the most commonly performed outpatient procedures that anesthesiologists assist with. But although some of the procedures can be quick and easy (comparatively speaking) for the surgeon, coding for the anesthesia portion can change from case to case.

A physician administers a pain block before the procedure begins, and a physician or other qualified anesthesia professional monitors the patient during the procedure. The coding challenge lies in knowing who is involved from an anesthesia standpoint during each portion of the procedure so you can report the services appropriately.

Case 1: Anesthesiologist Places Block, Nurse Observes

"If the anesthesiologist administers the presurgical retrobulbar block (the type of block most common for eye procedures), it can technically be coded as a stand-alone procedure instead of anesthesia services, according to CPT Codes and ASA guidelines," says Teresa Law, an independent anesthesia coding consultant with Physician Groups Ltd. in Winnepka, Ill. "But coding gets complicated if the anesthesia provider leaves once the block is in place and a nurse monitors the patient instead."

As long as the anesthesia provider is still present, the case is considered monitored anesthesia care (MAC). But once the anesthesiologist transfers the case to a nurse, Medicare guidelines maintain that it becomes a conscious sedation case. (That's because only anesthesia assistants [AA], certified registered nurse anesthetists [CRNA], and physicians trained in anesthesia can bill MAC services. By definition, MAC is excluded if a registered nurse monitors the patient.)

In this scenario, the anesthesiologist codes the initial block as a stand-alone procedure with CPT 67500 * (Retrobulbar injection; medication [separate procedure, does not include supply of medication]) but doesn't bill for the conscious sedation provided by the nurse (99141, Sedation with or without analgesia [conscious sedation]; intravenous, intramuscular or inhalation).

If this is how the physicians at your facility handle these cases, be sure you know each carrier's reimbursement guidelines. Some carriers include retrobulbar blocks in the ocular surgery payment, while others consider the block to be local anesthesia and bundle it with the anesthesia codes. If the carrier you're dealing with bundles the block payment with the surgical code, the surgeon and anesthesiologist should negotiate a fee arrangement.

Case 2: Surgeon Places the Block,
Anesthesiologist Monitors

 A more common approach to eye procedures involves the surgeon administering the initial block, and the anesthesia professional monitoring the case.

 "At our facility, the surgeon administers the blocks for eye cases, and we only administer MAC (unless the patient is a baby or if other special circumstances apply)," says Vicki Embich, a coder in the anesthesia department of West Florida Medical Center Clinic in Pensacola. "We only bill for the total sedation time, which in these cases can be as little as 7 minutes or up to 30 minutes or more."
 In addition to the physician's time, Embich also reports the appropriate anesthesia code for the procedure, which can include:

  • 00140 Anesthesia for procedures on eye; not otherwise specified
  • 00142 lens surgery
  • 00144 corneal transplant
  • 00145 vitreoretinal surgery
  • 00147 iridectomy
  • 00148 ophthalmoscopy.

    Case 3: Anesthesiologist Is Involved Throughout the Case

     The third possible scenario for this procedure involves the anesthesiologist from start to finish. He or she administers the initial block and then monitors the patient during the case. Pay attention to the times noted for the case, because you'll probably be billing for discontinuous time.

    For example, the anesthesiologist might be with the patient from 8:00-8:10 a.m. when placing the block, then 8:42-9:12 a.m. during the actual procedure, which is a total of 40 minutes of billable time.
     

    You should report the anesthesia during the procedure itself with the appropriate code from 00140-00148 as listed above. You cannot bill the initial block separately if the provider administers MAC for surgery because it (like other nerve blocks) is included in the global anesthesia fee.
     

    If you code for physicians in a teaching facility, pay attention to which members of the anesthesia team provide the services so you can report them correctly. Use performance modifier -AA (Anesthesia services performed personally by anesthesiologist) if the physician personally handles the entire case. Physicians working with residents often let the resident administer the block (after all, administering blocks is the most interesting part of anesthesia services and the part residents need to know best). The physician still reports the appropriate anesthesia code for the procedure but now appends modifier -GC (This service has been performed in part by a resident under the direction of a teaching physician) instead. (See "Correctly Document and Code Teaching Work" in the April 2003 Anesthesia and Pain Management Coding Alert for more information on coding for teaching physicians.)

     By the same token, use the correct modifiers for everyone involved if the anesthesiologist works with a CRNA (-QX, CRNA service: with medical direction by a physician; and -QY, Medical direction of one certified registered nurse anesthetist by an anesthesiologist). 


     Many practitioners believe they should have an anesthesiologist involved in all aspects of eye surgery, not just the initial blocks. This helps minimize the risk of the patient losing his eye if something unusual happens during the procedure (such as the patient moving, getting confused, having a heart attack, or difficulty breathing, etc.), or movement while his eye is opened for surgery, or when there are sharp instruments in the eye.

    Don't Forget MAC Modifiers, ICD-9 Codes

     Whichever team approach applies to these cases in your facility, don't forget to append MAC modifiers when appropriate. All states require modifier -QS (Monitored anesthesia care service) to designate MAC cases. Some states also require modifiers -G8 (Monitored anesthesia care [MAC] for deep complex, complicated, or markedly invasive surgical procedure) and -G9 (Monitored anesthesia care for patient who has history of severe cardiopulmonary condition) when appropriate. Check your local guidelines concerning the use of -G8 and -G9. Florida, for example, requires these modifiers, but New York does not.
     

    Some states or carriers also have very specific guidelines for coding MAC cases, especially regarding approved diagnoses supporting medical necessity. These include 250.02-250.03 (Diabetes mellitus without mention of complication; type II [non-insulin dependent type] [NIDDM type] [adult-onset type] or unspecified type, uncontrolled; and type I [insulin dependent type] [IDDM] [juvenile type], uncontrolled), 402.00-402.01 (Hypertensive heart disease; malignant; without heart failure; and with heart failure), and V14.4 (Personal history of allergy to medicinal agents; anesthetic agent).
     

    Even if you usually handle blocks and anesthesia for eye surgeries one way at your facility, there could be times when the circumstances change and you find yourself coding for a different level of involvement by the anesthesiologist. One rule of thumb to remember in these cases is to report an anesthesia code if the block or injection is used as the anesthesia for the surgical procedure and use the appropriate pain-management, nerve block or injection code instead if it is a stand-alone injection or procedure.

    • Other Articles in this issue of

    Anesthesia Coding Alert

    View All