Anesthesia Coding Alert

Fifteen to 20 percent of our physicians time is spent inserting catheters, says Mary Ann Trumpower, coder for Eastern Panhandle anesthesia in Martinsburg, W.Va. Thats why its so important to know whether the procedure is bundled with other services. Fortunately, catheter insertion codes are no longer bundled with other procedure codes, says Scott Groudine, MD, chairman of the government, legal and economic affairs committee of the New York Anesthesia Society.

Three of the most commonly used catheter insertion codes had been bundled with primary procedure codes and, therefore, were not billable separate fees. They are:

1. CPT 36620 (arterial catheterization or cannulation for sampling, monitoring or transfusion [separate procedure]; percutaneous);

2. CPT 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); and

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

Medicare clearly understands that the three codes for A-lines, CVPs and Swan-Ganz catheters are not bundled into anesthesia code and should get paid separately, Groudine says. This is a national policy, and all Medicare carriers must pay for these procedures if theyre medically necessary. Local carriers occasionally might deny separately billed procedures, but anyone who can prove medical necessity should fight the denial and be able to win.

Seeking reimbursement from other payers is a bit more complicated because their catheter-insertion policies vary regionally. For example, Blue Cross of Wisconsin, Maryland and Alabama recently considered bundling these procedures to some anesthesia codes. Blue Cross of Wisconsin claimed that central lines and A-lines are standard care for some surgeries, such as coronary artery bypass grafts, and therefore are not unusual monitors of care. Groudine says this view contradicts anesthesia guidelines, which state that unusual forms of monitoring (e.g., intra-arterial, central venous and Swan-Ganz) are not included as part of the usual pre- and postoperative visits, anesthesia care during the procedure, the administration of fluids and/or blood and the usual monitoring services (such as ECG, temperature and blood pressure).

Despite this conflict with CPT guidelines, coders say some large carriers, such as Blue Shield of California, still consider line placements bundled with anesthesia codes and, consequently, part of anesthesia delivery. This happens most frequently with claims for major procedures such as heart surgery. In this case, some anesthesiologists might write off the charges if the catheter was placed during his or her time in surgery, but will press for payment if the catheter was placed later because the service was performed separately from the main procedure.

Document Medical Necessity to Avoid Rejection

Documentation of heart problems, malignancies or organ failures satisfies medical necessity requirements for catheter insertions. Groudine offers these suggestions for documenting medical necessity for the different types of insertions:

When inserting a Swan-Ganz catheter (93503), you must describe a condition that warrants measuring pulmonary artery pressure, cardiac output and wedge pressures. Anesthesiologists often use diagnoses of heart failure, pulmonary hypertension or fluid status problems (such as sepsis or renal failure) to justify Swan-Ganz insertions.

When billing for central venous catheters (36489*), you must justify the need to measure central pressures during the procedure or to have access to the central circulation system. Neurosurgical procedures that might produce an air embolism also warrant placing a central access line. Intravenous hyperalimentation, renal failure, sepsis, massive fluid shifts and blood loss are medical justifications for central access.

Reimbursement for inserting A-lines (36620) requires justifying the need for frequent blood pressure monitoring or arterial blood gasses (ABGs) in certain situations. Some examples are procedures in which heavy blood loss is possible, for ill patients who cannot tolerate hyper- or hypotension because of conditions such as corotid stenosis, patients with coronary artery disease or malignant hypertension, and during hypotensive anesthesia. Multiple ABGs, which require an arterial line, are also medically necessary if ventilation during the procedure is expected to be prolonged or difficult.

Luckily, most carriers follow the CPT guidelines for billing catheter insertions if the accompanying documentation supports medical necessity. Weve never had problems getting paid for catheter insertions as long as the backup documentation was sent with the claim, Trumpower says. We always attach the doctors dictation of the procedure to the claim, and include documentation of the patients condition that supports medical necessity. Thorough documentation also helps if a payer denies a claim.

Documentation should also include the date and time of catheter placement and postoperative observations of the patient and clearly show that the anesthesiologist placed and monitored the line. You cannot bill separately for the catheter insertion if the anesthesiologist monitored the line but did not place it.

Consider Other Coding and Reimbursement Tips

Charges: Trumpower points out that catheter insertions are flat-fee services because they are surgical procedures that are not reported with anesthesia codes. Consequently, you cannot charge catheter insertions as base units. However, you can document and charge the anesthesia providers time with the patient in the same way as other procedures.

Codes for CVP Placement: CVP placement has two codes; your choice depends on the patients age. Code 36489* is used most often because it is for patients over age 2; 36488* is for younger children.

Local Carrier Guidelines: Your discussion with local carriers should include their documentation and medical necessity requirements for catheter insertions. Your contract should clearly state that catheter insertions will be treated and billed as separate procedures and paid accordingly.