Anesthesia Coding Alert

Question: Should the ICD-9 placed on the 1500 claim form be related to the procedure itself or the medical reason for requiring MAC?

Rhode Island Subscriber

Answer: The diagnoses given on the CMS 1500 claim form should always support the necessity of the procedure performed instead of being related to the anesthesia given (whether it’s MAC, general, etc.).

Example: A patient comes to the physician complaining of low back pain (724.2). After examination, the physician decides to perform a lumbar epidural injection. He gives an anesthetic at the site of the injection and then administers an anesthetic and/or steroid injection for pain management. The coder should report CPT® 62311 (Injection[s], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral [caudal]) and ICD 9 code 724.2 on the 1500 claim form.

You sometimes might also need a diagnosis to support the use of anesthesia in unusual circumstances. For example, a physician might request that a patient with cerebral palsy or Parkinson’s have anesthesia before undergoing an MRI. Patients don’t normally need anesthesia for MRIs, but these would be special circumstances to help make sure the patient stays still during the procedure. You would file with the diagnosis showing why the MRI was necessary, but would also include any other diagnoses to justify needing the anesthesia. Plus, you would append modifier 23 (Unusual anesthesia) to the CPT® code. Remember that modifier 23 applies to general anesthesia -- when a procedure usually requires no anesthesia or local anesthesia, but because of unusual circumstances must be performed under general anesthesia.