Advanced Search

Anesthesia Coding Alert

Piece Together Team-Member Coding for Complex Surgeries

Published on Thu Jan 01, 2004

Hint: Anesthesiologist's and other members' roles are key

Coding for complex surgical cases (such as surgery for major trauma or organ transplant) can seem like alphabet soup once you've included all the appropriate modifiers for anesthesia providers involved with the case. Here are two important steps to take when successfully report multiple-provider cases.

Step 1: Verify the Physician's Involvement

When more than one anesthesiologist is involved in a surgical case, the coding (and reimbursement) can get complicated. An anesthesia team may consist of two anesthesiologists who perform different services during the case (for example, one administers anesthesia while the other performs EKG monitoring, capnography, oximetry and BIS monitoring). Another common team pairs an anesthesiologist with one or more certified registered nurse anesthetists (CRNA), anesthesia assistants (AA), or anesthesia residents.
 
The anesthesiologist's payment varies, depending on his or her level of involvement with the case, says Cecelia McWhorter, BA, CPC, a coder with EmPhysis Medical Management Ltd. in Oklahoma City. He or she can be involved on three levels.
 

  • Personal performance.  When an anesthesiologist personally performs an entire procedure or is present and continuously involved in a single anesthesia procedure that a CRNA occasionally helps with, append modifier -AA (Anesthesia services performed personally by anesthesiologist) to the procedure's anesthesia code.

     

  • Medically directing. When a single case involves a CRNA, or up to four concurrent cases involve CRNAs, report these cases with modifier -QK (Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals) or -QY (Medical direction of one certified registered nurse anesthetist by an anesthesiologist). The anesthesiologist must meet all criteria for the Seven Rules of Medical Direction before you can submit claims as medical direction.
     
  • Medically supervising. When an anesthesiologist is involved in more than four concurrent procedures, or  when he performs other services while directing concurrent procedures, use modifier -AD (Medical supervision by a physician: more than four concurrent anesthesia procedures).
     
    Remember, if the surgery's complexity merits the presence of two anesthesiologists, the services are considered to be personally performed by each (-AA).


    Step 2: Determine Whether You're Dealing With a Large Team

    Highly complex procedures sometimes require the simultaneous services of several physicians, plus other highly skilled, specially trained personnel and complex equipment. These cases are carried out under the "surgical team" concept, says Albany, N.Y., anesthesiologist Scott Groudine, MD.
     
    "Many payers ask that participating physicians identify such circumstances by adding modifier -66 (Surgical team) to the basic procedure code used for reporting services and modifier -AA," Groudine says.
     
    For example, if a surgical team performs a heart-lung transplant, you should report surgical code 33935 (Heart-lung transplant with recipient cardiectomy-pneumonectomy) and the associated anesthesia code 00580 (Anesthesia for heart transplant or heart/lung transplant). Append modifiers -AA and -66 to the anesthesia code to indicate the anesthesiologists' roles. Each anesthesiologist also bills his or her time spent on the procedure by reporting 20 base units for anesthesia code 00580 plus the appropriate time units.
     
    "It's very important that providers document their work adequately," Groudine says. "Coders should realize that there's a good chance the claim will be rejected and that they'll need to speak with a carrier representative to explain the surgical situation and the need for two separately reimbursed anesthesiologists."
     
    In some instances, one member of the anesthesia team may start a case and another member may be called in to assume medical direction for the remainder of the case. Submitting claims for these cases - known as intraoperative handoffs - varies among states, so be familiar with your local carriers' guidelines.
     
    "Intraoperative handoffs are no big deal if the anesthesiologists are all in the same group, because how the money is paid is irrelevant since it ends up with the group," Groudine explains. "Problems start when the handoff is between nongroup members. Fortunately, it is rare for anesthesiologists to turn over patient care to 'competitors,' so the financial concerns don't exist."
     
    Some coders clarify with their carriers that they can satisfy medical-direction requirements in handoff situations if all the anesthesiologists' combined efforts meet the seven required steps (instead of requiring one anesthesiologist to complete all steps).
     
    Understanding reimbursement for cases involving CRNAs and being up-to-speed on the newly proposed teaching guidelines are two other important factors affecting your bottom line. Watch for more information on these in next month's issue.

    • Other Articles in this issue of

    Anesthesia Coding Alert

    View All