Anesthesia Coding Alert

Asking 2 big questions helps pinpoint the best code

Your physician provides anesthesia for a simple mastectomy with sentinel axillary node biopsy. But just because the procedure is called “simple” doesn’t mean your coding is: coders -- and carriers -- have different opinions on how to handle the situation, so ask yourself some questions before deciding the best coding option.

1. What Surgical Codes Apply?  

Anesthesia coding hinges on surgical coding, which complicates your job when carriers can’t agree on the best surgical code for a procedure.
 
First choice: Many coders report 19162 (Mastectomy, partial [e.g., lumpectomy, tylectomy, quandrantectomy, segmentectomy]; with axillary lymphadenectomy) for a simple mastectomy. But some carriers -- including the Centers for Medicare & Medicaid Services -- take a different stance. Consider this explanation from the 2005 Federal Register regarding the removal of breast tissue with nodes:

“In October 2004, the Centers for Medicare & Medicaid Services (CMS) clarified the correct coding of sentinel lymph node biopsy when performed in association with breast surgery. CMS will consider it correct coding for a provider to report CPT code 19160 (Mastectomy, partial [e.g., lumpectomy, tylectomy, quandrantectomy, segmentectomy]) plus 38500 (Biopsy or excision of lymph node[s]; open, superficial), when a sentinel node biopsy of superficial axillary with a lumpectomy is performed at the same session.”

But CMS agrees with reporting 19162 (instead of 19160) in two situations: when the surgeon performs an axillary lymphadenectomy and a lumpectomy, or when the surgeon erforms a sentinel lymph node biopsy followed by an axillary lympha-denectomy and a lumpectomy.

Another option: Some coders say 19180 (Mastectomy, simple, complete) could also be your best surgical code starting point, “based on the physician’s documentation of simple mastectomy with sentinel axillary node biopsy,” says Emma LeGrand, CCS, CPC, office manager for New Jersey Anesthesia Associates in Florham Park. She agrees with using 38500 for the sentinel axillary node biopsy.

“The key difference is the extent of the axillary dissection: superficial versus deep,” says Scott Groudine, MD, an Albany, N.Y,. anesthesiologist. “A deep axillary dissection takes more time and surgical skill and has more complications to consider. A full lymph node resection and breast biopsy would be at least a half hour.”

Double-check: When still in doubt about the extent of the procedure, turn to other pieces of the medical record -- such as the pathology report (which will refer to the biopsied nodes’ quantity and location) or surgical report -- to help direct your coding.

Because carrier guidelines can vary, contact your local carrier to verify its policy on how to report the simple mastectomy. 
 
2. What’s the Best Anesthesia-Code Choice?  

Once you determine the best surgical code for the patient’s mastectomy, you’ll shift to anesthesia options. The ASA Crosswalk seems to make the decision easy for you because it lists only two anesthesia options for the mastectomy:

• 00400 (Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; not otherwise specified) if you report surgical code 19160 or 19180; and

• 00404 (... radical or modified radical procedures on breast) if you report surgical code 19162.

Watch out: But don’t forget the sentinel axillary node biopsy. Code 38500 crosses to anesthesia code 01610 (Anesthesia for all procedures on nerves, muscles, tendons, fascia and bursae of shoulder and axilla), with alternative codes 00320 (Anesthesia for all procedures on esophagus, thyroid, larynx, trachea and lymphatic system of neck; not otherwise specified, age 1 year or older) and 00400 (Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; not otherwise specified).

The alternative codes 00320 and 00400 don’t apply to the patient in this case, so 01610 is the correct anesthesia code for the axillary node biopsy. 

Multiple-procedures reminder: The surgeon performed two procedures during this session, but your anesthesiologist can report only one. “When multiple surgical procedures are performed during a single anesthetic administration, only the anesthesia code with the highest base value is reported,” according to ASA coding guidelines. Anesthesia code 00400 for the simple mastectomy carries three base units; code 01610 for the sentinel axillary node biopsy carries five base units. Therefore, submit 01610 on the claim.

Document fully: Although you only report 01610, you’ll still report your physician’s total amount of time for both portions of the procedure. Include documentation of both services (the mastectomy and node biopsy) on your claim so the carrier will understand what took place.