Anesthesia Coding Alert

Nugget: Knowing which type of anesthesia is providednot just the type that is plannedis the key to reimbursement.

Anesthesiologists sometimes need to change the anesthesia plan due to complications with the patient or procedure. Even if monitored Anesthesia care (MAC) is planned for a procedure and is initially offered, that may change before the procedure ends. If an anesthesiologist crosses over from providing MAC to providing regional or general anesthesia, the change must be documented for proper reimbursement.

You never know how a patient will respond to anesthesia, points out Cindie Capito, physician Anesthesia coder for Southern Tier Anesthesiologists, PC, an Olean, N.Y., practice with nine physicians and seven CRNAs. Sometimes the anesthesia plan needs to change because complications will come up.

One such complication is when the patient needs assistance breathing, Capito says. If the level of MAC is so deep and complex that the anesthesia provider has to assist the patients breathing, then we consider it general anesthesia. If we have to breathe for the patient for a few seconds, we still consider it as a MAC case. But if we need to breathe for the patient for two or three minutes or more, we see it as crossing the line to general anesthesia. The anesthesiologist must document this in the patients chart by noting that the patient needed assisted breathing with a mask, or placement of an LMA (laryngeal mask airway) or a COPA (cuffed oral pharyngeal airway). The length of time the assistance is needed should also be noted on the patients chart.

Capitos guidelines are consistent with the American Society of Anesthesiologists (ASA) definition. The 1999 Relative Value Guide reads, Monitored anesthesia care refers to those clinical situations in which the patient remains able to protect the airway for the majority of the procedure. If, for an extended period of time, the patient is rendered unconscious and/or loses normal protective reflexes, then anesthesia care shall be considered a general anesthetic.

Coding for the Right Type

Even if there is not a change in the anesthesia plan, for reimbursement, anethesiologists must thoroughly document whether the anesthesia administered is MAC, general or regional. Joyce Lujic, an office manager with the 16-physician group Anesthesia Associates of New Haven in Connecticut, gives these examples of three procedures that could be treated with MAC or general/regional care, depending on the situation:

A CRNA provides anesthesia during a breast tumor excision under the medical direction of a physician. If MAC is provided, the case would be coded as 19120 (for the tumor excision) -QS (MAC) -QX (CRNA service: with medical direction by a physician). If the local carrier requires the new MAC modifiers, modifier -G8 (MAC for deep complex, complicated, or markedly invasive surgical procedure) would also be used. The same situation using a general anesthetic would be coded as 19120-QX.

An anesthesiologist provides care during bunion correction surgery. If MAC is provided, the case would be coded as 28296 (correction, hallux valgus [bunion], with or without sesamoidectomy; with metatarsal osteotomy [e.g., Mitchell, Chevron, or concentric type procedures])
-QS -AA (anesthesia services performed personally by anesthesiologist). The same case using general anesthesia would be coded as 28296-AA.

A 4-year-old child is scheduled for frenectomy ( code 41115, excision of lingual frenum [frenectomy]). She is not capable of remaining still while the surgeon cuts the frenum, cauterizes the bleeding and sutures the incision. Although this is a minor procedure that an adult would have with MAC anesthesia, a child will probably need general anesthesia instead.

You have to evaluate each patients physical status along with the type of procedure being done, and decide how you can complete the procedure in the safest manner, Capito notes. Some patients arent able to tolerate having a procedure done with MAC anesthesia. We usually do thrombectomies ( code 35875, thrombectomy of arterial or venous graft [other than hemodialysis graft or fistula]) with epidurals rather than MAC because most patients cant tolerate the pain.

Even if the procedure itself is not usually very painful, general anesthesia may be needed instead of MAC because of other circumstances.

Know the Difference Between MAC and Regional

MAC is often provided for procedures such as the excision of a breast cyst ( code 19120, excision of cyst, fibroadenoma, or other benign or malignant tumor aberrant breast tissue, duct lesion, nipple or areolar lesion [except 19140], male or female, one or more lesions), cataract removal ( code 66984, extracapsular cataract removal with insertion of intraocular lens prosthesis [one stage procedure], manual or mechanical technique [e.g., irrigation and aspiration or phacoemulsification]), or creation of an arteriovenous passage (code 36830, creation of arteriovenous fistula by other than direct arteriovenous anastomosis [separate procedure]; nonautogenous graft). All MAC services should be reported using the procedures CPT or ASA code (for Medicare cases) as well as modifier BQS (monitored anesthesia care service). Two new modifiers that were introduced in 1999 (-G8 and -G9) may also be required for MAC cases in addition to -QS, depending on whether the state where the service is provided requires them as additional documentation.

Physicians often prefer to use MAC when possible, because it offers advantages to the patients being treated. Updated drugs allow anesthesiologists to sedate patients heavily for very short periods of time so the surgeon can administer a local anesthetic to the area being operated on. Many patients who are treated with MAC are able to leave the hospital more quickly than patients who have general anesthesia.

When MAC is administered, the patient is sleepy but not unconscious. Fentynal or similar drugs can be administered as MAC, but not for long-term delivery as they would be for general anesthesia.

Regional anesthetics are injected into a particular region of the body (such as the shoulder or spine) and can be administered with other relaxants or anesthesia drugs with the patient either awake or asleep. Drugs can be given in addition to regional anesthesia in order to produce a full general anesthesia effect.

Many procedures that used to always be performed under general anesthesia began being performed with regional blocks. Now some of those procedures are being performed with MAC anesthesia instead. Three common examples of procedures that have gone through this process include hernia treatment (code 49505, repair initial inguinal hernia, age 5 years or over; reducible), TURPs ( code 52601, transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete), and hemorrhoidectomies ( code 42260, hemorrhoidectomy, internal and external, complex or extensive).