Anesthesia Coding Alert

From diagnostic procedures through surgery and breast reconstruction, the anesthesiologist is a key member of a patient's breast-cancer care team. While much of the coding associated with the diagnosis and treatment can be straightforward, knowing how to report services performed by the anesthesiologist can be tricky.

When breast cancer is suspected, the anesthesiologist may provide services associated with biopsy and staging. Beth Hibbs, CCS-P, an American Health Information Management Association certified coder in Spokane, Wash., notes that biopsies include local or intravenous sedation, and sometimes monitored anesthesia care (MAC), for certain procedures. Scott Groudine, MD, an anesthesiologist in Albany, N.Y., says that the administration of local anesthesia is usually performed by the surgeon and thus included in the global surgical fee. "Almost every Medicare carrier considers anesthesiology services unnecessary when local anesthesia is used. While an anesthesiologist may put in a local, they must also provide MAC or general anesthesia to justify the medical necessity for billing the service."
 
Hibbs says, "The majority of biopsies performed in our area fall under 19125 (Excision of breast lesion identified by preoperative placement of radiological marker, open; single lesion). Two additional codes also define common biopsy procedures 19102 (Biopsy of breast; percutaneous, needle core, using imaging guidance) and 19103 ( percutaneous, automated vacuum assisted or rotating biopsy device, using imaging guidance)."
 
For the anesthesiologist, all of the procedures noted above can be coded using the appropriate surgical and anesthesia code 00400 (Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; not otherwise specified), which carries a base value of three units plus time. Groudine warns, however, that 19102-19103 describe minimally invasive procedures that rarely require an anesthesiologist's services. "If an anesthesiologist bills for these procedures, the claim is likely to be denied. Worse yet, routine submission of anesthesia claims for these procedures may prompt local Medicare carriers to develop local medical review policies (LMRPs) which severely restrict anesthesia reimbursement for breast services."
 
Mary Jo Marcely, CPC, senior vice president of NAPA Services, a consulting and medical billing firm in Syracuse, N.Y., advises coders to check their LMRPs and the guidelines of other carriers when using MAC. "Many LMRPs require appending modifiers to the anesthesia code. These might include modifiers -QS (MAC service), -G8 (MAC for deep complex, complicated, or markedly invasive surgical procedure), or -G9 (MAC for patient who has history of severe cardio-pulmonary condition)."
 
"For more invasive procedures, such as 19101 (Biopsy of breast; open, incisional), administration of MAC or general anesthesia is the norm," Hibbs says. In this case, coders should submit claims using 19101 and 00400 (and a MAC modifier if necessary).

Surgical treatments for breast cancer include lumpectomy and partial, total or radical mastectomy. CPT 2002 lists a number of codes for each of these procedures:

 Lumpectomy:
 

19120 Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion (except 19140), open, male or female, one or more lesions

 

19125 Excision of breast lesion identified by preoperative placement of radiological marker, open; single lesion

 

+19126 each additional lesion separately identified by a preoperative radiological marker (list separately in addition to code for primary procedure).

Partial mastectomy:
 

19160 Mastectomy, partial
 

19162 with axillary lymphadenectomy.

 Total mastectomy:

 

19180 Mastectomy, simple, complete
 

19182 Mastectomy, subcutaneous.

 Radical mastectomy:

 

19200 Mastectomy, radical, including pectoral muscles, axillary lymph nodes
 

19220 Mastectomy, radical, including pectoral muscles, axillary and internal mammary lymph nodes (Urban type operation)
 

19240 Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis minor muscle, but excluding pectoralis major muscle.

Note: Code +19126 is not a primary procedure and has no corresponding anesthesia descriptor. For these procedures, the primary code is 19125. Code 19140 (Mastectomy for gynecomastia) should be used only if gynecomastia (611.1) is the diagnosis.
 
In Hibbs' experience, a common procedure is a partial mastectomy with axillary lymphadenectomy (19162). During surgery, the surgeon excises tissue from the breast and the lymph nodes. "For anesthesia, we code to the highest base procedure. In this scenario, a lymphatic procedure is being performed in addition to a simple breast procedure. The correct surgical code would be 19162, with an associated anesthesia code of 00404 (Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; radical or modified radical procedures on breast). Code 00404 has a base value of five units plus time."
 
Hibbs provides another example for coders. "A lumpectomy (19120) was performed with a lymphangiotomy (38308, Lymphangiotomy or other operations on lymphatic channels). We would code our anesthesia session to the higher base procedure of 38308, which crosses with 01610 (Anesthesia for all procedures on nerves, muscles, tendons, fascia, and bursae of shoulder and axilla), rather than 19120, which crosses with 00400."
 
Sentinel lymph node biopsy is often performed in conjunction with mastectomies (although it can be performed in a separate session). As described by HGSAdministrators, Pennsylvania's Medicare carrier, this technique allows sampling of the lymph node(s) that receive drainage from a tumor or an area of carcinoma. The sentinel node is the first node to which the dermal lymphatics around a tumor drain. If the sentinel node biopsy is negative, the patient is spared lymphadenectomy. Relevant codes for this procedure are 38500-38542 and 38792. Many of these codes were revised in 2001, so coders should check that descriptions match the procedures performed.
 
The sentinel nodes are often biopsied after a mastectomy is preferred. Groudine notes, "Frequently, 38525 (Biopsy or excision of lymph node[s]; open, deep axillary node[s]) is used by the surgeon for the procedure. If most of the axillary nodes are removed with the breasts, then 19162 is the appropriate surgical code. If only the sentinel node is removed, then 19120 and 38525 might be used. For the anesthesiologist, it is best to bill using the same surgical codes as the surgeon with the appropriate anesthesia code. Irrespective of which codes are used for surgery, I recommend all anesthesia for breast surgeries that involve axillary lymphatics be coded with 01610."
 
One of the most important things for coders to remember is to link the correct diagnosis with the CPT code. Examples include primary breast tumor (174.9) and carcinoma in situ (233.0). This is crucial when reporting procedures associated with breast cancer. Marcely states, "Coders need to indicate whether breast cancer is the primary or secondary diagnosis and whether the breast cancer has metastasized from another organ, such as the lung. ICD-9 codes should be sequenced appropriately on claims, with the primary diagnosis listed first, and any secondary diagnoses subsequently."

Breast reconstruction procedures are listed in CPT 2002 as 19316-19396. These procedures crosswalk with 00402 (Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; reconstructive procedures on breast [e.g., reduction or augmentation mammoplasty, muscle flaps]), with a base value of five units plus time.
 
"Most local Medicare carriers cover reconstructive surgeries, whether they are transverse rectus abdominis myocutaneous (TRAM) flap or an implant," Hibbs says. "The only thing they don't cover is a revision to the abdomen when the TRAM flap creates 'dog ears,' caused by a poorly healed incision where the ends of the scars are raised in a triangular shape resembling a dog's ears. Medicare and many commercial carriers view this as cosmetic and not medically necessary."
 
"If the carriers pay for surgery, they will pay for the reconstruction," Marcely says. "However, we don't always see coverage for surgery on the opposite breast to create symmetry. Their rational is that this surgery can be seen as cosmetic, but I would argue that augmentation of the opposite breast wouldn't be necessary if the patient didn't have to undergo a mastectomy in the first place."
 
She suggests that all claims for reconstructive procedures be preauthorized, and that when submitting claims for payment, coders include the same diagnosis codes as used for the patient's mastectomy. Also, include a note stating that the reason for the dissymmetry is breast cancer and that reconstructive measures on both breasts are clinically best physiologically and psychologically for the patient. "Deformity caused by breast cancer treatment can have a profound effect on a patient's well-being. We have been asked by some insurance carriers to submit a psychological evaluation along with claims for certain reconstructive procedures to help substantiate the need for surgery."
 
"It is important to inform the insurer that reconstructive procedures are not cosmetic," Groudine adds. "Cancer reconstructive surgeries should be obvious on the claim with the use of correct cancer ICD-9 codes. By avoiding ambiguity, coders can avoid unnecessary conflict in getting these claims paid."