Anesthesia Coding Alert

Question: How do you handle the medical necessity for anesthesia on a procedure that, according to the local coverage determination (LCD), does not routinely require anesthesia? I think our office needs to have a form or something that documents the reason anesthesia is required for the procedure. Can you share ideas or verbiage with me?

New Mexico Subscriber

Answer: The diagnosis code for the condition that made anesthesia medically necessary might be enough to support the use of anesthesia in some situations (such as when the patient is a very young child), but it depends on how thorough your provider’s documentation is.

The clearer the documentation of why the patient needed anesthesia, the better your chances of gaining reimbursement with the original claim or if you have to file an appeal. Here are a few examples of documentation that might prove useful:

• “The patient is 2 years old and unable to understand or follow instructions.”
• “Due to [the patient’s [medical condition] the patient cannot hold still for the duration of the procedure.”
• “The patient required monitored anesthesia care because the patient’s history of [medical condition] placed them at greater risk for [bad thing] during the procedure.”

Coding tip: Be careful when trying to justify anesthesia because of the patient’s anxiety. You need more than notes stating that the patient was nervous about having a medical procedure; the anxiety must be documented at a level that couldn’t be addressed with basic medication or other tactics.