Anesthesia Coding Alert

Tip: Keep your eyes open for non-OR cases you should submit

Treatment rooms have become common fare in hospitals, meaning your anesthesia providers are helping with non-traditional cases more often. Follow your carriers' guidelines when submitting these claims, and remember to append modifier 23 (Unusual anesthesia) when appropriate.

Treat Treatment Rooms as Separate 

Physicians now perform a variety of minor procedures in their hospitals' treatment rooms. Many of these cases only require local anesthesia, but your providers might administer general anesthesia -- and therefore qualify for submitting modifier 23 -- for some of these procedures:
 
• Line removal: 00400 (Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; not otherwise specified) or 00532 (Anesthesia for access to central venous circulation).
 
"If a patient is severely mentally challenged or has severe tremors due to a medical condition and cannot cooperate, then anesthesia may need to be involved," says Lorraine Gledhill, CPC, an anesthesia coder with Lahey Clinic in Burlington, Mass.
 
• Suture removal or dressing change: 00400, 00300 (Anesthesia for all procedures on the integumentary system, muscles and nerves of head, neck and posterior trunk, not otherwise specified), or another appropriate anesthesia code for the treatment location. "A patient's condition could warrant anesthesia in extraordinary circumstances," Gledhill says.
 
Example: A patient had a deep perineal wound that would not heal and kept requiring special care. When the physician removed the wound dressing, anesthesiologists from Gledhill's group participated in the procedure due to the patient's condition (15852, Dressing change [for other than burns] under anesthesia [other than local]).
 
• Cast changes or removal:  Needing anesthesia during a cast change or removal is an exception rather than the rule, but small children might sometimes require it, says Emma LeGrand, CPC, CCS, coding supervisor of New Jersey Anesthesiologists in Florham Park.
 
Code anesthesia for these cases according to the cast site, such as 01130 (Anesthesia for body cast application or revision), 01490 (Anesthesia for lower leg cast application, removal or repair) or 01680 (Anesthesia for shoulder cast application, removal or repair; not otherwise specified).

Know the Rules Before You Submit

If you think a case qualifies for modifier 23, "Know the rules pertaining to using and reporting the modifier," says Kelly Dennis, CPC, owner of Perfect Office Solutions in Leesburg, Fla. Some carriers have their own guidelines for when you should report modifier 23. Dennis shares a few examples:
 
• HGSA requires you to list the modifier in the second position and file the claim with documentation.
 
• HGSA also uses modifier 23 to indicate a physician's presence for induction when used with modifier AD (Medical supervision by a physician: more than four concurrent anesthesia procedures) and allows one extra unit of reimbursement for the procedure.
 
• Blue Cross/Blue Shield of Alabama uses modifier 23 to indicate that a vaginal or cesarean delivery lasted longer than four hours.

Appeals help: Knowing the rules doesn't lead to automatic acceptance, so you can find yourself appealing claims with modifier 23. When that happens, LeGrand recommends that you emphasize the medical necessity for general anesthesia during the procedure, such as the patient's mental or physical status or age. Also include a letter of medical necessity from the primary-care physician or surgeon to help bolster your position.
 
Final note: Checking your providers' documentation for details regarding medical necessity, general anesthesia versus monitored anesthesia care and procedure specifics can help make or break your modifier 23 claims.  
 
See "Modifier 23 Can Help Ensure Payment for Non-OR Services" in the June Anesthesia & Pain Management Coding Alert for more on correctly reporting modifier 23 with non-OR procedures.