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® code 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 diagnosis 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. 

However: Some payers might direct you to submit the appropriate physical status modifier to describe the situation rather than additional explanatory diagnosis codes. For example, the policy from Blue Cross/Blue Shield Alabama states, “When submitting a monitored anesthesia claim for gastrointestinal (GI) endoscopy, a bronchoscopy, or pain procedures described in Medical Policy #470, please use the diagnosis code that describes the reason for the procedure, not the rationale for using monitored anesthesia. The use of physical status modifiers P3 (A patient with severe systemic disease) or P4 (A patient with severe systemic disease that is a constant threat to life) indicates the presence of a systemic disease necessitating monitored anesthesia care. … The grounds for using MAC will be indicated by the physical status on the claim.”