Anesthesia Coding Alert

Follow this guide to help assign the correct code

The surgeon's global fee for procedures includes routine pain management, but surgeons often ask for help with more difficult cases. If your pain management specialist evaluates patients for postoperative pain management, verify that you can code for the service -- and be sure you assign the correct-level code.

Meet the Requirements  

Before you can code a visit as a consult, your physician must meet certain criteria. In the past, physicians had to meet guidelines known as "the three R's" of consult coding, but now the guidelines have expanded to include four R's instead: request, reason, render (an opinion) and report.

"Reason" is the newest addition to the requirements and can be difficult to substantiate.
 
"The main problem with the fourth R is getting the physician to dictate the reason for the consult," says Barbara J. Johnson, CPC, MPC, owner of Real Code Inc. in Moreno Valley, Calif.

"Simply indicating 'pain consult' will not justify a consult code," Johnson says. "Now the documentation must indicate specifics such as 'patient with low back pain, referred by Dr. A for consult' to show the reason for the request."

Check Out the Options

CPT 2006 made some changes to consult codes, including deleting the follow-up inpatient consultation codes. Now you should report subsequent care codes (99231-99233, Subsequent hospital care, per day, for the evaluation and management of a patient ...) for these situations, according to CPT notes.
 
Selecting the correct code depends on the level of care provided: the amount of medical history taken, the extent of physical examination given, and the complexity of medical decision-making.

The global anesthesia fee includes routine postoperative management, and the global surgical fee includes routine postoperative surgical care (including pain management).

"If an anesthesiologist has seen the patient, and the patient is referred by another physician (with a written request outlining the necessary information and why this patient is more complicated than the typical post-op patient), you can consider billing the service as a consultation," says Scott Groudine, MD, an anesthesiologist in Albany, N.Y.

That's when documentation can help justify coding a consult for the patient.
 
Watch Times for Coding Clues

In most cases of inpatient consults, you'll report 99251 for consultative post-op care, Groudine says, "because the history and physical is problem-focused (limited to pain), and the medical decision-making is straightforward with an average time of 20 minutes spent with the patient."

Time it: Encouraging your physicians to keep timed notes will lead to more accurate coding. The length of the visit can give you insight into the visit's complexity, Groudine says. 

CPT tip: Notes following each of the consult codes in CPT include an explanation of how complex the patient's problem typically is and how long the physician should spend with a patient during that level of visit. Comparing your physician's documentation to CPT's notes can help point you toward the correct code: 

• 99231 for visits with the patient or in the patient's unit lasting about 15 minutes
• 99232 for 25 minutes
• 99233 for 35 minutes.

Knowing the time your physician spent with the patient is helpful but is only a guide -- not a definitive ruler. "If the time falls short or long, look at the exam," Johnson says.

"The times are estimates of average visits at the E/M level," Groudine says. "You must meet all requirements to bill at an E/M level, but time can give clues about the complexity of the visit."

Example: A 10-minute visit is not long enough for the physician to perform a comprehensive or complex examination. At the opposite extreme, if your physician spends several hours with the patient but you only have documentation of a problem-focused history, you cannot code higher than 99231.

Test Yourself  

Coding a consult begins with the physician who requests your anesthesiologist's expertise. Do your anesthesia providers have enough information up-front to help justify coding follow-up consults? Check your opinion against our experts' recommendations:

Scenario 1: The surgeon's office calls to ask your anesthesiologist to perform a pain consult after Mrs. Smith's surgery on Thursday.

Recommendation 1: You will not be able to code this visit as a consult unless you get substantially more documentation from the surgeon. A phone call can be a good heads-up, but the surgeon must make the consult request in writing.

Scenario 2: The surgeon's office faxes a request asking your anesthesiologist to conduct a pain consult after Mrs. Smith's surgery on Thursday.

Recommendation 2: In the past, this could be the starting point for possibly coding a consult because you have written documentation requesting your anesthesiologist's service. But the documentation lacks one of the criteria for today's consults: a detailed reason for service that would suggest that this is different from routine postoperative pain management.

Scenario 3: The surgeon's office sends a note to your office, asking that your anesthesiologist conduct a consult after Mrs. Smith's surgery on Thursday. She is scheduled for hip replacement surgery but has complicating factors: She has severe lung disease and is overly sensitive to pain medications. The surgeon wants your anesthesiologist to evaluate her postoperative status and recommend a course of treatment.

Recommendation 3: This documentation is well on the way to justifying a consult charge. You have the surgeon's request -- in writing -- asking for your anesthesiologist to examine the patient and offer an opinion on her condition and treatment options. You also have the reason for the consult; now your anesthesiologist just needs to document his service to help support a consult code.