Anesthesia Coding Alert

The American Society of Anesthesiologists (ASA) lists billing Medicare for patient-controlled anesthesia (PCA) as one of the "top 10 pain-medicine risk areas." Therefore, it's worth considering its proper coding.
 
The ASA instructs pain physicians not to use "either ASA code 01997 (daily management of patient-controlled anesthesia), which has never been adopted by the CPT editorial panel, or an E/M code." According to the ASA, Medicare considers PCA to be a hospital-nursing service, not a physician's professional service.
 
In its local medical review policy on epidural catheters, Georgia Medicare states that PCAs are "an adjunct to the surgical care during the postoperative period to relieve postoperative pain. It is considered a part of the surgeon's global fee for the surgery performed."
 
Billing for PCA or for an inpatient visit when only PCA monitoring was performed is fraudulent, says Devona Slater, CMCP, an anesthesia and pain-management specialist in Leawood, Kan. But, she notes, "If the physician provided legitimate E/M services at the same time as PCA is provided, they should be separately payable."
 
Some private carriers, she adds, are asking for refunds for previously reimbursed PCA treatments.
 
"Unlike epidurals that require inspection of the catheter site and are riskier and more complex services, PCAs are relatively simple to monitor and are well within the surgeon's ability to set up. Although anesthesiologists and pain physicians best understand PCAs and the drugs they utilize, it is not necessary to have these specialists manage PCA, because it is fairly uncomplicated and can be taught. In fact, some orthopedic and ob/gyn floors in some hospitals employ nurses that are specially trained to deal with PCAs," Slater says. "If the nurses encounter any difficulty, then they call the pain specialist (who would then be able to bill for an inpatient consultation), but normal, routine management of PCAs by the pain specialist is not required."
 
Even if the PCA is placed via an epidural, it should not be billed to Medicare carriers or, increasingly, to private carriers. Nor should hospital-inpatient E/M codes be used, Slater says. "Just because the pain-management specialist looks in on the patient and switches medications" doesn't mean it's separately billable "as this is something the surgeon should be able to do that is part of the surgery's global package."
 
If a complication arises (i.e., the pump may not be functioning properly, the medication does not provide the expected level of pain control, the patient is in extreme pain, or perhaps has received an overdose of the medication and the general surgeon wants more expertise in handling the situation) a request for a consultation with a pain specialist may be made. In such cases, assuming the criteria for a consult are met, the pain specialist could bill for an inpatient consultation (99251-99255).
 
Clear and accurate documentation is required to obtain payment. "You need to document that the pain specialist's expertise was required, that it wasn't just a case of the surgeon 'handing off' the patient after the operation," says Martina Heasley, CPC, an administrator in the department of anesthesia at Stanford University in Stanford, Calif. "The documentation needs to show why the patient was special."