Anesthesia Coding Alert

Hint: Showing medical necessity can make all the difference.

Reporting anesthesia during endoscopic gastrointestinal procedures. has undergone tremendous coding changed in 2018. Conflicting information from the CPT^® and the Center for Medicare and Medicaid Services (CMS) is making coding these services extremely challenging this year. Be sure to pair your coding option with a solid supporting diagnosis and follow payer guidance to ensure your claims find success.

Know How to Crosswalk the Procedure

CPT^® divides anesthesia codes for endoscopic gastrointestinal procedures by "upper" and "lower." Your choices are:

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

Tip: According to CPT^®, "Report 00812 to describe anesthesia for any screening colonoscopy regardless of ultimate findings. However, CMS indicates that "When screening colonoscopy becomes dx colonoscopy, 00811 should be submitted with only -PT modifier and only deductible will be waived."

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 -33 modifier will also be required in order to correctly waive the patient's coinsurance and deductible. The surgeon must also report the service as a screening procedure through the use of either G0105 or G0121.

Report 00811 for a diagnostic colonoscopy to Medicare (and payers that follow Medicare guidance). A -PT modifier should be appended to appropriately waive the patient's deductible and they are still responsible for the coinsurance.

For payers who follow CPT^®, you will report 00812 for a screening colonoscopy whether it become 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.

Dig Out Details for the Best Diagnosis

Administering anesthesia during EGDs or other gastro procedures is more common than in years past, but payers still look for strong supporting diagnoses that justify the need for anesthesia. 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)
• Mental subnormality or retardation (F70, F71, F72, F73, F70)
• 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: 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 Dennis, MBA, ACS-AN, CAN-PC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Fl. "Make certain you understand specific payer policies regarding separate anesthesia services for these procedures."

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

Understand Multiple Procedure Options for Upper/Lower GI

The gastroenterologist might perform more than one procedure during the encounter. This year, there is a code to report both an upper and lower GI procedure.

Guideline:  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." However, this year, both resources direct you to report 00813 with the combined (or total) time for both procedures with the new single anesthesia code.

Example: The physician completes an 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.

Don't Let Payer Guideline Changes Throw You

Different payers might have different guidelines for MAC during endoscopic procedures, so do your homework before filing claims. Follow the old-fashioned approach of researching and contacting each individual insurance carrier to get their billing and reimbursement guidelines.

Reasoning: "A claim denied by one carrier might be processed smoothly by a different carrier," 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."

Bottom line: Periodically check your payers' policies to ensure coverage status hasn't changed. The time you spend confirming details now will pay off with easier claims processing later.