Anesthesia Coding Alert

Hint: Get clear documentation supporting medical necessity to boost your chances.

Whether you're new to anesthesia coding or have years of experience to your name, you know that billing for your providers' involvement with endoscopic and GI procedures is never a cut-and-dry situation. But, if you understand the differences between your code choices and take time to learn payer policies, your gastro claims will be as smooth as possible.

Step 1: Get Familiar With Your Anesthesia Choices

CPT^® 2017 differentiates the codes for anesthesia during endoscopic gastrointestinal procedures as "upper" or "lower." Here's what you need to know about each of your three options.

00740 (Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum): As the code you report for EGD (or esophagogastroduodenoscopy), you'll probably turn to 00740 quite often. It carries a base value of 5.

00790 (Anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; not otherwise specified): Submit 00790 for gastric procedures orlaparoscopic gallbladder procedures. It carries a higher base value, with 7 units.

00810 (Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum): Turn to 00810 for anesthesia during a colonoscopy. As with 00740, code 00810 has a base value of 5.

Possibly add a MAC modifier: Many anesthesiologists administer MAC (monitored anesthesia care) during these procedures rather than general anesthesia. When that's the case, remember to append the appropriate MAC modifiers as needed. For Medicare patients, that means including modifier QS (Monitored anesthesia care service). You might also be able to append modifier G9 (Monitored anesthesia care for patient who has history of severe cardio-pulmonary condition), depending on the patient's medical history (and if you have documentation that supports it).

Step 2: Drill Down to a Supporting Diagnosis

Although administering anesthesia during endoscopic gastro procedures is more accepted today than in years past, payers still check that you have a diagnosis supporting its use.

Important: The diagnosis that supports anesthesia should be tied to a co-existing medical condition, not the gastrointestinal condition that led to the procedure. Diagnoses that could possibly support your anesthesiologist's work include:

• Parkinson's disease (G20)
• Heart conditions (such as the codes from I21, ST elevation [STEMI] and non-ST elevation [NSTEMI] myocardial infarction, or I49.01, Ventricular fibrillation)
• Mental subnormality or retardation (F70-F79, ...Intellectual disabilities)
• Seizure disorders (such as R56.9, Unspecified convulsions)
• Anxiety (such as F41.1, Generalized anxiety disorder).

Another option: You might also be able to submit a diagnosis for failed sedation attempts. Those options are T88.52XA (Failed moderate sedation during procedure, initial encounter) or Z92.83 (Personal history of failed moderate sedation).

"Specific diagnosis codes for failed moderate sedation or a history of failed sedation can really help justify anesthesia," says Kelly D. Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Fla. "The challenge is to make certain that the documentation supports using the codes. Notes that describe the patient's previous history of failed sedation in the pre-anesthesia or pre-operative assessment will indicate the patient's unique situation."

QC lends support: Sometimes another code (instead of or in addition to the diagnosis) will support the need for anesthesia. For example, performing the procedure on a patient of extreme age could allow you to include the "qualifying circumstances" code +99100 (Anesthesia for patient of extreme age, younger than 1 year and older than 70 [List separately in addition to code for primary anesthesia procedure]).

Important: Remember, however, that Medicare doesn't allow additional payment for modifier QC or physical status modifiers.

Step 3: Watch for Differences by Payer

Before getting too far with your claim, ensure you're up-to-date on the payer's guideline for MAC during endoscopic procedures.

"Check your major payers' online policies if they're available," Dennis advises.

"A claim denied by one carrier might be processed smoothly by a different one," says Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the AMA's CPT®'s Advisory Panel. "The policy for anesthesia coverage and payment methodology is not standardized amongst Medicare intermediaries or non-Medicare carriers."

What to do: Go through your payers' policies on a regular basis to verify that coverage status hasn't changed. The time you spend confirming details now will pay off with easier claims processing later.

"You should check policies at least once a year," Dennis says. "The beginning of the year is a good time for it. Put it on your practice's year-end to-do list."

Step 4: Focus on a Single Anesthesia Code

It's not uncommon for the gastroenterologist to complete more than one procedure during the encounter – but that doesn't mean you report multiple anesthesia codes.

Reminder: CPT^®'s anesthesia guidelines for separate or multiple procedures instruct you to report the "most complex" procedure from the encounter. The American Society of Anesthesiologists directs you to bill the "anesthesia code with the highest base unit value." Calculate the time units based on the combined (or total) time for all procedures the surgeon performs, but tie those units to a single anesthesia code.

Example 1: The physician completes an EGD and colonoscopy during a single encounter. Your anesthesiologist documents a combined start/end time of 60 minutes. Because codes 00740 and 00810 each have the same base value of 5, you can submit either code with the total amount of time.

Helpful tip: If you're reporting a screening colonoscopy with an EGD, report the screening colonoscopy and matching diagnosis. "If there is a straight screening (which you'll designate with modifier 33, Preventive services), many payers waive the deductible and co-pay," Dennis says. "If a polyp is found (modifier PT, CRC screening test converted to diagnostic test or other procedure), the payer will still waive the deductible."

"At this point we're all aware of and used to appending modifier 33 and PT as applicable to our screening colonoscopies," adds Cindy Hinton, CPC, CCP, CPCO, with Advanced Coding Solutions, LLC, in Franklin, Tenn. "It eases reimbursement, so when an operative session includes both an EGD and a screeningcolonoscopy, the colonoscopy might be more easily reimbursed."

Since the EGD and screening colonoscopy are worth the same number of base units, you can choose to report the colonoscopy. "Just make sure your primary diagnosis indicates a screening (Z12.11, Encounter for screening for malignant neoplasm of colon)," Hinton says, "followed by the findings. Also still include modifiers 33 and PT as applicable."

Example 2: The gastroenterologist completes an upper intraperitoneal procedure or laparoscopy during the same encounter as an EGD or colonoscopy. Because code 00790 carries a base unit value of 7, you'll submit 00790 instead of 00740 or 00810, with the combined total time for both procedures.

Example 3: It's not uncommon to see EGDs performed with dilation of the esophagus – but Hinton warns to not assume that 43249 (Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic balloon dilation of esophagus [less than 30 mm diameter]) is the correct code before you cross to an anesthesia option.

"Make sure you know whether the dilation was performed with or without the scope," she says. "Many times, the physician has withdrawn the scope and might perform the dilation by unguided sound or bougie, or over guidewire."

If this is the case, either 43450 (Dilation of esophagus, by unguided sound or bougie, single or multiple passes) or 43453 (Dilation of esophagus, over guide wire) might be the better procedure code. These codes represent an increase in anesthesia base units – from five to six. "Don't leave that extra unit on the table," Hinton says.

Esophageal dilation is indicated and widely reimbursed for conditions such as malignancy, esophagitis, esophageal ulcers, and stricture. Coverage will vary by payer and policy, but watching for these diagnoses and supporting documentation can potential bring more money to your provider.