Anesthesia Coding Alert

Read what some experts say.

Your anesthesiologist documents that he administered general anesthesia and placed a double lumen catheter during a patient’s lung biopsy. Can you separately report the anesthesia for the procedure and the double lumen? Some coding experts weigh in on the matter.

Pinpoint the Surgical Technique

As with many procedures, you need to know the surgeon’s approach in order to choose the correct anesthesia code. Your two first-line choices are 00522 (Anesthesia for closed chest procedures; needle biopsy of pleura) or 00540 (Anesthesia for thoracotomy procedures involving lungs, pleura, diaphragm, and mediastinum [including surgical thoracoscopy]; not otherwise specified), depending on whether the surgeon performed a needle biopsy or thoracotomy.

The base value for 00522 is 4 units; the base value for 00540 is 12 units.

Understand Why Double Lumen Might Be Used

In the example scenario, inserting a double lumen catheter allows the anesthesiologist to use one lung ventilation (OLV) during the procedure.

In most patients requiring mechanical ventilation, the anesthesiologist inflates and deflates both lungs together. One lung ventilation refers to mechanical separation of the two lungs to allow ventilation of only one lung, while the other lung is compressed by the surgeon or allowed to passively deflate. OLV is a standard approach to improve exposure to the surgical field for pulmonary and other thoracic surgeries. Providers might also choose to use OLV to isolate one lung from the other because of a pathologic process in one lung.

Know How It Could Affect Your Bottom Line

FYI: Experts point out that additional money is available for putting a patient on one lung ventilation. That’s why double lumen tubes are placed, but a single lumen tube and bronchial blocker also will produce OLV. First see whether the record states that the patient was on OLV. If so, you can use one of the higher-unit codes that reward the additional work.

Potential anesthesia codes when OLV is used are:

• 00529 (Anesthesia for closed chest procedures; mediastinoscopy and diagnostic thoracoscopy utilizing 1 lung ventilation), which is a mediastinoscopy approach to biopsy where OLV is done. With a base value of 11, code 00529 is rated higher than a standard mediastinoscopy approach but much less than a thoracotomy.
• 00541 (Anesthesia for thoracotomy procedures involving lungs, pleura, diaphragm, and mediastinum (including surgical thoracoscopy); utilizing 1 lung ventilation) is a thoracotomy using OLV and is worth more than 00529 (15 units). A double lumen that’s not used could be argued as not being medically necessary. If OLV is provided, then the codes that pay extra for it compensate for the extra work.

Take note: The one lung ventilation codes typically include the extra work involved for services such as a double lumen, but this can depend on the procedure performed and the payer involved. Some payers will allow you to append modifier 22 (Unusual procedural service) when the double lumen is documented as medically necessary and is patient-specific. This will not automatically increase your fee.

If you append modifier 22 for the double lumen, some insurers require documentation when you file the claim. Others don’t require reports with the initial filing, but you must have documentation in the medical record if it’s requested. Check with the payer to determine its policy on reporting double lumens.

“Coders have different opinions on whether modifier 22 is appropriate in these situations, and private insurers can process claims how they choose,” says Kelly Dennis, MBA, ACS-AN, CAN-PC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Fl. “In my opinion, however, the extra value (4 units) makes up for the additional work needed to place the double lumen.”

What Is a Double Lumen Catheter?

A double lumen catheter (also called a dual lumen catheter or a two-way catheter) has two channels, one for injecting fluid and the other for removing fluids. Using a double lumen catheter allows the anesthesia provider to administer all the patient’s IV medications and to take most of the patient’s blood samples. It reduces the need to insert needles into veins, which is more comfortable for the patient. Double lumen catheters can be inserted for a surgical procedure and removed afterward or can be in place long-term while the patient undergoes medical treatment. In those situations, the double lumen allows the provider to administer more than one medication at a time without the drugs mixing before they reach the patient’s bloodstream.

Dennis also points out that coders need to understand how and where one lung ventilation is documented on the anesthesia record.

“Although electronic anesthesia records (EARs) are usually clear to read, on paper records sometimes the anesthesia providers use notes or comments that may be either spelled out, abbreviated as OLV, or just arrows pointing up and down when the lung is deflated and inflated,” she says. “If the writing is not legible, the OLV may be overlooked. Coders should pay attention to the length of surgery and whether a double lumen was indicated under equipment and follow up, if necessary. Just because a double lumen was placed, doesn’t mean it was used.”

Takeaway: One lung ventilation can help your reimbursement, but should only be billed when the anesthesia record/graph clearly shows that the lung was deflated (down) and re-inflated (up). The same holds true for double lumen catheters – watch for clear documentation and only report it separately when you feel confident that it’s justified.