Anesthesia Coding Alert

In 2001, anesthesiologists gained two codes for coronary artery bypass graft surgery (CABG): CPT 00563 (anesthesia for procedures on heart, pericardium, and great vessels of chest; with pump oxygenator with hypothermic circulatory arrest) and 00566 (anesthesia for direct coronary artery bypass grafting without pump oxygenator). Even though these codes are more specific, they still hold challenges.

Determining which code to use for the anesthesiologists service depends on two factors: whether the surgeon uses a pump oxygenator (commonly called the heart-lung machine) during the surgery and whether you have a detailed description of how the procedure was performed.

Note: The two original codes for CABG are 00560 (anesthesia for procedures on heart, pericardium, and great vessels of chest; without pump oxygenator) and 00562 ( with pump oxygenator). Although the 2001 codes replace these older ones, to process your claims some carriers might insist you use the old codes.

Did the Surgeon Use a Pump?

The majority of CABGs in our area are performed with a pump oxygenator, but were starting to see a small percentage without a pump, says Tonia Raley, CPC, a claims processing team leader with the Phoenix consulting firm Medical Information Management Solutions. The new codes, and the frequency of heart procedures without a pump, make it imperative for anethesia providers to chart which technique was used for the procedure. Coders need more specific information to match the more specific codes; they can no longer assume 00562 automatically applies.

When the pump is used, it keeps the patients blood flowing to the brain and other organs while the heart is stopped during surgery, explains Barbara Johnson, CPC, MPC, anesthesia coding specialist with the physician group Loma Linda Anesthesiology Medical Group Inc. in California. When the pump isnt used, the patients heart isnt completely stopped. This is a relatively new approach to CABGs that cuts down on the patients risks and includes benefits such as quicker recovery time.

Although anesthesias involvement in CABGs is the same in either case, coders must know which approach was used because the base units, and consequently reimbursement, for these codes differ. For example, if a patient undergoes a direct CABG without the pump oxygenator, it is coded with 00566, which has a base value of 25.

However, Raley sometimes finds that while local insurance companies allow the new 2001 codes for the procedure, Medicare carriers do not. In this case, the only alternative is to use the old 00560 code because it has a more general definition for procedures on the heart, pericardium and great vessels that dont use the pump oxygenator. The problem is that 00560 is a 15-unit procedure and the new 00566 is 25 base units. This obviously makes a big difference in the bottom line.

Which Lines and Who Placed Them?

Coders need specific information about the lines used in CABG procedures to determine whether the insertion can be billed separately. For example, placement of intra-aortic balloon pumps (IABP), central venous pressure catheters (CVPs) and Swan-Ganz lines can be considered separate procedures and, consequently, are billed in addition to the CABG itself if certain requirements are met.

Raley says one of the most important criteria for separate billing is who placed the lines. An anesthesiologist cannot bill separately for lines another physician or technician placed (even if the anesthesiologist uses the lines for monitoring purposes during the surgery). Payment is for line insertion, and monitoring these devices is part of the anesthesia fee, according to HCFA. Therefore, the anesthesia provider must clearly document that he or she personally placed the line(s) to bill them separately.

Also, some lines cannot be billed simultaneously, such as a CVP and Swan-Ganz, because they are inserted through the same sheath (i.e., the CVP port might be used to thread the Swan-Ganz catheter, so only the Swan-Ganz can be billed). However, you can bill both lines if the anesthesia record clearly shows they are separate and both are medically necessary. Procedures involving medical necessity include drug infusion, volume replacement or pressure monitoring.

When lines qualify for separate billing, you can use several codes, including:

36620 arterial catheterization or cannulation for sampling, monitoring or transfusion [separate procedure]; percutaneous;

36489* placement of central venous catheter [subclavian, jugular, or other vein] [e.g., for central venous pressure, hyperalimentation, hemodialysis, or chemotherapy]; percutaneous; over age 2;

93503 insertion and placement of flow directed catheter [e.g., Swan-Ganz] for monitoring purposes.

To bill separately for IABP, use codes 33970 (insertion of intra-aortic balloon assist device through the femoral artery, open approach) and 93536 (percutaneous insertion of intra-aortic balloon catheter).

The final question is: Should you append modifier -59 (distinct procedural service) when billing separately for the lines? Raley says the answer depends on your local carrier. If the payer does not normally bundle the line placements with the primary procedure, you can probably code them separately. But if the carrier bundles line placements with the procedure, Raley recommends appending -59 to the line placement code and including thorough documentation to justify the separate status.

Note: For more information on billing for line placements, see the December 2000 and April 2001 Anesthesia Coding Alert.