Anesthesia Coding Alert

Most payers will not reimburse for pain managementunless they have a precise description of the service, why it was provided, and the condition of the patient. This is a truism that can be translated to most medical practices, but in anesthesia pain management particularly it is unique and critical.

Modifiers are extremely important because they disclose exactly whats going on with the patient, says Lisa Hahn, anesthesia billing specialist with Lakefront Billing Service in Milwaukee, Wis. And, with the field of pain management growing, its imperative for accurate coding and recording and full reimbursement to keep abreast of which modifiers carriers accept for particular situations.

Use Modifiers Skillfully to Report Pain Services

Anesthesiologists use a select group of modifiers to report pain-management services, says B.J. Johnson, CPC, MPC, anesthesia coding specialist with Loma Linda University Anesthesiology Medical Group in Loma Linda, Calif. Following are modifiers anesthesiologists use most:

modifier -22 (unusual procedural services): Append this modifier to the procedure code when the anesthesiologist provides services beyond routine. For example, most patients do not require anesthesia during diagnostic procedures such as MRIs (magnetic resonance imaging) or CAT (computerized axial tomography) scans (anesthesia code 01922, anesthesia for non-invasive imaging or radiation therapy). However, physically challenged patients or infants might need anesthesia during the procedure. Modifier -22 is appropriate in this situation.

modifier -23 (unusual anesthesia): This modifier indicates services such as administering anesthesia for MRIs, CAT scans, radiation therapy or lumbar punctures for infants.

modifier -24 (unrelated evaluation and management service by the same physician during a postoperative period): Johnson says anesthesiologists rarely use this modifier, but it is appropriate in some circumstances. For example, if an anesthesiologist has to see a patient with an implanted pain pump for a different pain problem, the service is reported with modifier -24 appended to the applicable procedure code.

modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service): Append this modifier when a patient requires an evaluation and management (E/M) service that is above and beyond the routine care associated with a procedure. Anesthesiologists often attach this modifier to report administering pain blocks. For example, an anesthesiologist completes an expanded history and physical that requires straightforward medical decision-making for a new patient (99202). If the workup indicates the need for a nerve block that same day, use 62311 (injection, single [not via indwelling catheter], not including neurolytic substances, with or without contrast [for either localization or epidurography], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or subarachnoid; lumbar, sacral [caudal]) appended with modifier -25 to show that the nerve block was a separate service from the evaluation.

modifier -26 (professional component): Some procedures, such as fluoroscopy, combine professional and technical components. Modifier -26 documents the professional component of a service when the physician does not own the equipment used. For example, an anesthesiologist performs an epidural steroid injection (ESI) under fluoroscopy, but the hospital owns the fluoroscopy equipment. The anesthesiologist would bill for the ESI (62311) and the fluoroscope as 76000-26 ( fluoroscopy [separate procedure], up to one hour physician time, other than 71023 or 71034 [e.g., cardiac fluoroscopy]).

Modifier -26 is appended to show that the anesthesiologist is billing only for the professional component of the service.

modifier -50 (bilateral procedure): Unless otherwise noted in CPT, its appropriate to report bilateral procedures performed during the same session by appending modifier -50 to the correct procedure code. For example, 64470 (injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; cervical or thoracic, single level) is listed as a unilateral code. Therefore, if an anesthesiologist administers the injections bilaterally, you report the procedure as 64470-50 to indicate that both sides of the area were treated.

modifier -51 (multiple procedures): Hahn says her group frequently uses this modifier, particularly when a provider performs multiple procedures other than E/M services at the same session. Pain practitioners commonly use modifier -51 for billing multiple trigger point injections. The first injection is coded as 20550* (injection, tendon sheath, ligament, trigger points or ganglion cyst), with additional injections reported as 20550-51.

modifier -58 (staged or related procedure or service by the same physician during the postoperative period): If the anesthesiologist implants a temporary pain pump or nerve stimulator for a patient, then two weeks later implants a permanent one, the operative report accompanying the claim must state the service was a planned, staged procedure. Attaching modifier -58 to the procedure code on the claim signals the payer that the procedure was exactly that.

modifier -59 (distinct procedural service): Anesthesiologists often use this modifier when reporting postoperative pain-management services. The surgeon and/or anesthesiologist might determine prior to the procedure that the patients postoperative pain will be significant enough to warrant higher-level pain management. So, they insert a catheter after the surgery to manage the post-op pain. The catheters placement is coded 62318 (injection, including catheter placement, continuous infusion or intermittent bolus, not including neurolytic substances, with or without contrast [for either localization or epidurography], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or subarachnoid; cervical or thoracic) or 62319 ( lumbar, sacral [caudal]), depending on the catheters location. In this case, append modifier -59 to mark the epidural as separate and distinct from the anesthesia provided in the original procedure.

modifier -60 (altered surgical field): Some procedures are more complicated or take more time than expected because the surgeon has to deal with the effects of previous surgery, inflammation or marked scarring. Modifier -60 would be attached to the procedure code if the physician has to lyse many adhesions before the anesthesiologist can implant a pain pump.

modifier -76 (repeat procedure by same physician): Use this modifier if the anesthesiologist needs to repeat a procedure. If the carrier considers members of the same group to be the same physician (carriers have different interpretations), you could use modifier -76 when an epidural catheter (62318 or 62319) that was placed during surgery for post-op pain management has failed and another member of the group replaces it.