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.). It’s important to be aware of any state-specific rules related to medical necessity. For example, the MAC medical necessity policy from Alabama Blue Cross/Blue Shield 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.”

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 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 (333.71, Athetoid cerebral palsy) or Parkinson’s (332.0, Paralysis agitans) 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.