Anesthesia Coding Alert

Once you've correctly documented these areas, start coding for the actual care. You should report 01996 for each day of post-op care, and the provider should document anything related to the patient's care. Details regarding the patient's level of pain and subsequent relief, medication plan and any side effects all help you accurately code the case.

Append Modifier -59 for First Day

Some carriers do not require modifiers to distinguish postoperative care from anesthesia service, but this can vary by state. Most carriers do need modifier -59 (Distinct procedural service) to distinguish post-op pain management from the anesthesia used for surgery, says  Kelly Dennis, CPC, ACS-AP, owner of the consulting firm Perfect Office Solutions in Leesburg, Fla. 
 
And some coders even recommend always appending modifier -59 to the case as back-up documentation, even if the carrier doesn't require it.
 
"You only report modifier -59 on the first day of post-op care," says Cheryl Pascale, CCS, a coder with Hackensack Anesthesiology in Hackensack, N.J. "I haven't had problems reporting modifier -59 with post-op care, but you should always check your carrier's policy."

Factor in Carrier Caps

Most patients typically do not need acute pain services beyond three days; sometimes even one or two days of care is sufficient. The anesthesiologist decides this as he assesses the patient during the follow-up visits. Patients might need longer-term post-op pain management because of:

 

"We commonly turn off the epidural but leave it in while we transition the patient to other analgesia," says Scott Groudine, MD, an Albany, N.Y., anesthesiologist. "If the transition isn't successful, the epidural is still in place and we can restart it. Once satisfactory pain control is obtained, we can remove the epidural catheter."
 
Tip: Know the carrier's policy regarding the number of acceptable follow-up days. Some carriers' policies prohibit follow-up care beyond three days unless you submit additional documentation to support the need. Groudine's group submits copies of the physician's progress notes to document the need for continued therapy.
 
Other carriers might have guidelines that you'll want to clarify.
 
Example: Florida's Medicare carrier (Firstcoast) has a policy stating that it will not pay for daily management "which exceeds the frequency and duration indicated by standards of medical practice." The policy does not define "standard practice," so Dennis says getting clarification - in writing - of this type of vague wording will help you submit claims that are more likely to be accepted.
 
Most coders say they don't see many denials for post-op care beyond three days, partly because they rarely bill for it. When you do report it, be sure your physicians document the reason for extended care (such as the patient's pain level) to help justify the claim.
 
"If a provider receives a denial for exceeding the frequency limit, he must submit hospital records to support the medical necessity," Dennis says. "This is where their documentation is going to come in handy."

Stay Focused Through the Last Day

One of the biggest challenges of post-op pain management coding comes at the end of care: Do you bill for pulling the catheter? Coders have three schools of thought on this issue:

 

The physician groups you code for and the carriers you deal with will help determine how to code the final day, but many coders and physicians seem to think that some type of coding for the final day is appropriate.
 
"The last day of pain management includes management from the start of the day (midnight) until the physician removes the catheter," Groudine says. "We don't typically pull the catheter at midnight, which means some pain management care has occurred on the day the cath is pulled."
 
Groudine points out that the physician will discuss future pain management options with the patient before discontinuing the catheter. "If you simply pull out the catheter without doing anything else, maybe you shouldn't bill," he says. "But if you've been managing the catheter for part of the day and have set the patient up for the next stage of pain treatment (pills or otherwise), it is entirely proper to bill for your visit."