Anesthesia Coding Alert

Question: When I was trained in anesthesia I was told to charge an H&P as 99202-25 along with 01480 for foot procedures to all payers except Medicare because they do not pay for it. I am now questioning a couple of things. First, should there be separate documentation for billing the H&P aside from the anesthesia record? Shouldn't time be recorded as well? Code 99202 is for a new patient, therefore, this wouldn't apply to all patients. Would we switch 99202 for 99213 for an established patient?

West Virginia Subscriber

Answer: If the patient has a foot procedure, the base allowance includes her history and physical (similar to a pre-anesthesia questionnaire). Don't bill the E/M service separate from 01480 (Anesthesia for open procedures on bones of lower leg, ankle, and foot; not otherwise specified) unless your provider didn't render any type of anesthesia service. In that case, the physician's documentation must support the E/M code you select and the related history, physical examination, and medical decision making process elements.