Anesthesia Coding Alert

Question: Our anesthesiologist provided several services while performing a consultation with an intensive care unit patient: intubation, A-line insertion, CVP placement, fiberoptic bronchoscopy, vasopressor management, critical care management during the patient's transfer to tertiary care, and ventilator management. Which of these services can I code?


Virginia Subscriber

Answer: You'll need answers to several questions before you can code this scenario. Who requested the consultation and why? How long did the physician spend on the consult, and did he complete a report that helps justify charging a consult? Was the patient "critical" while being prepared for transfer to tertiary care?

Critical care counts: If the patient was critical, start by billing 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and +99292 (... each additional 30 minutes [list separately in addition to code for primary service]) as appropriate. The critical care codes include intubation and ventilator and vasopressor management, so you won't bill separately for those services.

You can bill separately for the A-line insertion, CVP (central venous pressure access device) placement and bronchoscopy. Report the A-line insertion with 36620 (Arterial catheterization or cannulation for sampling, monitoring or transfusion [separate procedure]; percutaneous) or 36625 (... cutdown), depending on the physician's technique (although you'll rarely use 36625).
 
Report the CVP placement with 36555 (Insertion of non-tunneled centrally inserted central venous catheter; under 5 years of age) or 36556 (... age 5 years or older) based on the patient's age.
 
The correct bronchoscopy code depends on why the physician needed to perform it. Get more details about the bronchoscopy, then choose the correct code from the series 31622-31656.

Remember: Any time that the physician spends on the separately billed procedures (such as the line insertions) is separate from the critical care time. Don't include those time units when you calculate the time he spends on critical care.

Noncritical option: If the patient was not critical, report the appropriate E/M code from 99231-99233 (Subsequent hospital care, per day, for the evaluation and management of a patient ...).

Append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). Then report the additional services separately, as outlined above.