Anesthesia Coding Alert

Procedure Focus:

Follow 4 Steps to Gastro Claims Success

Published on Tue Mar 08, 2022

Hint: Solid documentation of medical necessity will play in your favor.

Reporting anesthesia during endoscopic gastrointestinal procedures is much more common than in years past, but payers still want strong supporting diagnoses and documentation of the service. Following these four steps (in addition to following each payer’s guidelines) will simplify the process and bolster your chances for success.

Step 1: Correctly Crosswalk the Procedure

CPT^®currently includes six anesthesia codes representing endoscopic gastrointestinal procedures. They are distinguished by “upper” and “lower”:

00731 (Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum; not otherwise specified)
00732 (Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum; endoscopic retrograde cholangiopancreatography (ERCP))
00790 (Anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; not otherwise specified)
00811 (Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; not otherwise specified)
00812 (… screening colonoscopy)
00813 (Anesthesia for combined upper and lower gastrointestinal endoscopic procedures, endoscope introduced both proximal to and distal to the duodenum)

Pay attention: CPT^®coding guidelines direct you to “Report 00812 to describe anesthesia for any screening colonoscopy regardless of ultimate findings.” However, the Centers for Medicare & Medicaid Services (CMS) states that “When a screening colonoscopy becomes a diagnostic colonoscopy, anesthesia services are reported with CPT^®code 00811 and with the -PT modifier; only the deductible is waived” (Medicare Claims Processing Manual, Chapter 18, Section 60.1.1).

Step 2: Mind Your Modifiers

Modifiers reported on Medicare claims may differ from other payer guidelines if the payer follows CPT^®guidance. Report 00812 for screening colonoscopy to Medicare (and payers that follow Medicare guidance). You may find that a modifier 33 will also be required to correctly waive the patient’s coinsurance and deductible. The surgeon must also report the service as a screening procedure by submitting either G0105 (Colorectal cancer screening; colonoscopy on individual at high risk) or G0121 (… colonoscopy on individual not meeting criteria for high risk).

Report 00811 for a diagnostic colonoscopy to Medicare (and payers that follow Medicare guidance). Modifier PT (Colorectal cancer screening test; converted to diagnostic test or other procedure) should be appended to appropriately waive the patient’s deductible (the patient will still be responsible for the coinsurance).

When submitting to payers who follow CPT^®guidelines, you should report 00812 for a screening colonoscopy whether it becomes diagnostic or not.

If you are still having problems getting paid correctly, you may need to contact the payer to determine which guidance they are following.

Step 3: Determine the Best Diagnosis

If applicable, your claim should also include a diagnosis that indicates a co-existing medical condition that supports the anesthesiologist’s involvement, not just the gastrointestinal condition leading to the procedure.

Potential diagnoses could include:

Parkinson’s disease (G20)
Heart conditions (such as I21.-, Acute myocardial infarction or I49.01, Ventricular fibrillation)
Intellectual disabilities (F70, F71, F72, F73)
Seizure disorders (such as R56.9, Unspecified convulsions)
Anxiety (such as F41.9, Anxiety).

You might also be able to submit a diagnosis for failed sedation attempts if the patient has experienced trouble with sedation in the past. Look to T88.52XA (Failed moderate sedation during procedure, initial encounter) or Z92.83 (Personal history of failed moderate sedation).

“Billing for endoscopic and GI procedures remains fluid,” says Kelly D. Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Florida. “Make certain you understand specific payer policies regarding separate anesthesia services for these procedures. Don’t presumptively assign a diagnosis code based on payer guidelines. Ask your clinical staff to document whether screening services are applicable.”

“The challenge is to make certain the documentation supports the codes reported on your anesthesia claim,” Dennis adds. “Notes in the pre-anesthesia or pre-operative assessment should support the patient’s reported condition.”

Step 4: Watch for Multiple Procedure Options

Under some circumstances, the gastroenterologist might perform more than one procedure during the encounter. Typically, CPT^®’s anesthesia guidelines for separate or multiple procedures instruct you to report the “most complex” procedure. The American Society of Anesthesiologists recommends you bill the “anesthesia code with the highest base unit value.”

That’s not necessary when the surgeon performs upper and lower GI procedures during the same encounter. Instead, you’ll turn to anesthesia code 00813, which is assigned a base value of 5. Submit 00813 with the combined (or total) time for both procedures.

Example: The physician completes an esophagogastroduodenoscopy (EGD) and colonoscopy during a single session. Your anesthesiologist documents a combined start/end time of 22 minutes for both procedures. For this combined procedure, you will report 00813.

However, if the physician completes an upper intraperitoneal procedure or laparoscopy during the same encounter as an EGD or colonoscopy, you’ll want to follow the typical anesthesia coding guidelines and submit 00790 (base unit value of 7) with the combined total time for both procedures.

Final tip: Payer policies regarding coding and reimbursement for upper and lower GI procedures can vary — and coverage status can change from one year to the next. Take time to check your payers’ policies to ensure you’re following their latest guidelines. Some old-fashioned research can pay off through easier claims processing.