Anesthesia Coding Alert

Question: Medicare denies our claim for anesthesia during excision of a mass in a patient's breast. The surgeon reported 19120 (Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion [except 19140], open, male or female, one or more lesions). A CRNA performed the service without medical direction, so we appended modifier -QZ (CRNA service: without medical direction by a physician). We coded 611.72 (Lump or mass in breast) for the supporting diagnosis.

North Carolina Subscriber
 
Answer: The excisional breast biopsy code crosswalks to anesthesia code 00400 (Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; not otherwise specified). These procedures usually are MAC (monitored anesthesia care) cases, so be sure to append the correct modifier for it. Report modifier  -G8 (Monitored anesthesia care [MAC] for deep complex, complicated or markedly invasive surgical procedure) instead of the basic MAC modifier -QS (Monitored anesthesia care service), if your carrier accepts -G8 and -G9 (Monitored anesthesia care for patient who has history of severe cardiopulmonary condition).

If the CRNA administered general anesthesia, you need to initiate a phone appeal because the MAC rules were applied in error.

You should also be familiar with the supporting diagnoses that your Medicare carrier allows for MAC cases. Code 611.72 does not provide documentation of medical necessity for anesthesia care, so investigate whether the patient has an underlying condition that supports medical necessity.

Carriers sometimes require a diagnosis that reflects the medical necessity for anesthesia in addition to a diagnosis code for the actual procedure. One diagnosis the carrier might accept is 217 (Benign neoplasm of breast), but be sure you have the supporting pathology report before using this.