Anesthesia Coding Alert

Long-term use can help justify MAC

Details about a patient's medication history -- specifically his use of high-risk medications -- can help justify anesthesia in nonstandard cases. Read on for expert advice on how to put this knowledge to work for you.

Pay Close Attention to High-Risk Meds

All medications fall into risk-level categories. The challenge for you as a coder is to train your physicians to list all of a patient's medications on the chart so you can determine if any affect your coding.

-Oftentimes, providers neglect to tell us about a patient's underlying conditions,- says Leslie Johnson, CCS-P, CPC, of River Oaks Imaging and Diagnostics in Houston. -But they almost never neglect to tell us the names of medications the patient currently takes.- 

Once you know what medications a patient takes, pay close attention to the ones considered to be high-risk (including Vicodin, Percocet, Oxycontin, Valium and others). Then find out how long the patient has taken the high-risk medication, and get ready to submit claims for services you might otherwise not be able to file.

Long-Term Use Can Justify MAC

ICD-9 includes several codes for long-term (current) drug use. Code V58.69 (Long-term [current] use of other medications) includes high-risk medications and can be your ticket to more accurate coding and reimbursement.

Example 1: Mrs. Jones is scheduled for an MRI. She's very anxious about feeling claustrophobic, so the radiologist asks your physician to administer MAC (monitored anesthesia care) during the procedure to help her relax. Mrs. Jones- carrier denies reimbursement, saying the anesthesia is not justified. 

On the other hand, Mr. Brown is also scheduled for an MRI. He has taken diazepam (Valium) to manage his agoraphobia (300.20, Phobia, unspecified) for three years. His carrier agrees that administering MAC during the MRI will help Mr. Brown tolerate the procedure, so approves your anesthesiologist's involvement. In this case, report the anesthesia with 01922 (Anesthesia for non-invasive imaging or radiation therapy) and append modifier QS (Monitored anesthesia care service).

Example 2: Physicians in some hospitals (primarily teaching facilities) are beginning to perform vascular bypass procedures under MAC instead of general anesthesia due to patients- heart conditions. Because these patients typically take long-term medications and have underlying conditions to justify MAC, the carrier should reimburse your anesthesiologist.

Note: In this case, remember to append modifier G9 (Monitored anesthesia care for patient who has history of severe cardio-pulmonary condition) to the anesthesia code in addition to modifier QS. 

Defining -Long-Term- Can Be Tricky

Once you know that the patient takes a high-risk medication, the next question to ask is, -What constitutes long-term use?-

The answer is a definite gray area because no official guidelines exist to define -long-term.-

-Medicare wants to know how long the patient has been on the medication, but you just have to take the patient's word for it,- Johnson says. -Trying to determine how long is -long-term- is the same as asking, -How big is big?- -

The anesthesia record won't reflect this information, says Kelly Dennis, CPC, owner of the consulting firm Perfect Office Solutions in Leesburg, Fla. Instead, you-ll typically find these details in the pre-anesthesia evaluation or assessment form.

As a portion of the American Society of Anesthesiologist's documentation guidelines states, -The [anesthesia] record should include documentation of the pre-anesthesia evaluation.- The evaluation includes a patient interview to assess his medical history, anesthetic history and medication history. A thorough medication history should include details about high-risk medications the patient takes, why the patient takes the medications and the prescribing physicians.

Stop Searching for the Magic List

One of the easiest ways for you to know how to handle these claims would be to have a master list of high-risk medications. Unfortunately, our sources say that list doesn't seem to exist.

You, however, can pay attention to medications that tend to be red flags to anesthesia providers. Investigate how long the patient has taken medications such as:

- Antidepressants -- citalopram, bupropion and sertraline
- Anti-inflammatories -- naproxen, celecoxib, ibuprofen
- Antihypertensives -- diltiazem, propranolol, moexipril
- Anticoagulants such as welfarin (Coumadin) can interact with many other medications. An especially bad mix is warfarin and any nonsteroidal anti-inflammatory drug (NSAID), such as aspirin, ibuprofen or naproxen. This combination can lead to serious bleeding.
- Narcotic pain relievers such as Vicodin, Oxycontin or Lortab make your liver metabolize anesthesia quickly. That means the patient needs more medication sooner than expected.

Bottom line: Many in-the-trenches coders seem to agree that high-risk medications taken for one year or longer should constitute long-term use. Because no official guidelines are in place to help your coding in these situations, watch for these medications and talk with your physicians and carriers to determine when medications will help justify MAC for procedures.