Anesthesia Coding Alert

Question: We have an anesthesiologist who wants us to bill separately for an IM injection with meds for pain management and post-op nausea. Isn’t the administration of meds included in the anesthesia service? According to the NCCI edits I read, this would be unbundling unless I didn’t read that correctly.

Texas Subscriber

Answer: You are correct. Both the American Medical Association (AMA) and CPT^® guidelines state that codes such as those for an IM injection are not intended to be reported by a physician in a facility setting. Instead, the physician normally orders the injection and the nursing staff administers it. If a separately identifiable E/M service is performed on the same day, that could potentially be reported and payable.

In addition, the NCCI Policy Manual states that “96360-96376 (Drug administration)” is considered an integral service to the anesthesia procedure until the patient is released by the anesthesia practitioner to the care of another physician. Therefore, a separate IM injection with pain management medications is not separately billable.