Anesthesia Coding Alert

Billing for an anesthesiologist's postoperative services -- such as epidural analgesia, nerve blocks (a routine part of pain management beyond the surgical suite) and patient-controlled administration of analgesia -- frequently challenges coders and billers, because these procedures are sometimes bundled with the surgical payment. The key to reimbursement is coding these services so Medicare and private carriers recognize them as separate and distinct from services of other providers, such as the surgeon.

Coding Postoperative Consults

 
Cindy Parman, CPC, CPC-H, principal and co-founder of Coding Strategies Inc., a coding consulting firm in Dallas, Ga., says, "In general, payers consider the operating surgeon as providing the postoperative pain management and many make it part of the global surgical payment. Other carriers, however, allow separate reimbursement when the surgeon requests in writing that the anesthesiologist offer advice or manage the patient's in-hospital postoperative pain." 
 

Scott Groudine, MD, an anesthesiologist in Albany, N.Y., says, "If the anesthesiologist is requested to evaluate pain management of a patient in the hospital after surgery, and has not performed the operative anesthesia , 99251 (initial inpatient consultation for a new or established patient) is the most commonly used code for the initial in-patient consultation.  This is because most patients require only a problem-focused evaluation. Codes 99252-99255 (initial inpatient consultation for a new or established patient) might also be suitable, depending upon the level of care, complexity of the examination, and degree of medical decision-making. As with any E/M service, the three key elements (history, examination and medical decision-making) must be documented in the patient's medical record.
 
"However," Groudine adds, "if a member of the anesthesia group provided services for the patient's surgery, and a consult on the same day, then append modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M codes to distinguish it from other procedures performed that day."
 
As stated in CPT 2001, if, subsequent to the completion of the consultation, the consulting anesthesiologist assumes responsibility for management of a portion or all of the patient's condition(s), you would not use the follow-up consultation codes. In the hospital setting, the physician should use the appropriate inpatient hospital-consultation code for the initial encounter and then subsequent hospital-care codes, 99231-99233.

Post-Op Pain-Management Procedures

Epidural Pain Management
 
In the postoperative period, hospital in-patients who have had major surgical procedures such as hysterectomy, spinal arthrodesis or radical nephrectomy might be continuously infused with pain medication through an epidural catheter.
 
The anesthesiologist can bill for placing a catheter intended for postsurgical pain management during surgery -- if the line is not used for anesthesia administration during the operation. But Parman says it is important to subtract the time required to place the catheter from the surgery anesthesia time so the catheter insertion can be billed separately.
 
Medicare will pay for this catheter insertion with codes 62318 (injection, including catheter placement, continuous infusion or intermittent bolus; cervical or thoracic) or 62319 (injection, including catheter placement, continuous infusion or intermittent bolus; lumbar, sacral [caudal]), whichever is appropriate. Many coders advise appending modifier -59 (distinct procedural service) to the catheter-placement codes to affirm that the procedure was separate and distinct from the anesthesia provided during surgery.
 
"Reimbursement for catheter insertion is typically higher than for the anesthesia time units required to place the catheter, so you should bill the insertion whenever possible and, of course, appropriate," advises Groudin. Because most anesthesiologists choose to place epidural catheters in awake patients, it is relatively easy to start anesthesia time after placement, he says.
 
Epidural drug administration for a hospital patient, 01996 (daily management of epidural or subarachnoid drug administration), is eligible for Medicare reimbursement after the day the anesthesiologist inserted the catheter. If the surgeon inserts the catheter, the anesthesiologist time for daily management of drug administration can begin the same day and be billed with 01996. Follow-up care in this case is covered for a maximum of three days; continued care might be covered if claims are submitted with a special report documenting medical necessity. Parman suggests that the report include a note from the physician stating why extended epidural drug administration is medically necessary, and why other forms of analgesia (such as nerve blocks or oral medication) have been ruled out. If there are notes from a postoperative consult provided by a physician other than the surgeon stating the need for extended care, they should be included as well.

 
Note: While most Medicare and some commercial carriers reimburse for epidural drug administration under CPT anesthesia code 01996, some commercial payers will not. Often they prefer that providers use a subsequent hospital care E/M code, 99231-99233. Parman advises that coders ask their carriers how to report daily management of the epidural.

Administration of Nerve Blocks
 
Medicare states that when the anesthesiologist administers an injection/block postoperatively -- in the recovery area -- as part of his or her anesthesia time, any additional time required for the injection can be included in the total number of anesthesia units reported.  Subsequent adjustments or injections for this same nerve block are considered routine postoperative pain management, regardless of who performs it, and are not eligible for separate payments.
 
If the patient's postoperative pain is managed with forms of analgesia other than epidural drug administration, Groudine says that the anesthesiologist's care could include consultative E/M services, such as those described under codes 99251 and 99261. "If the anesthesiologist provides postoperative in-hospital pain management, you can bill for subsequent hospital care (99231-99233) if the documentation supports this level of care," Groudine says. "Nerve blocks (64400*-64530*) or trigger-point injections (e.g., 20550) should also be covered by most commercial carriers because they have zero global days. Again, some coders recommend appending modifier -59 (distinct procedural service) to indicate that the procedures were independent of the surgery."

Patient-Controlled Analgesia (PCA)
 
Typically, the surgeon and/or the anesthesiologist prescribes the PCA, determines the baseline and subsequent dosage, and is responsible for the medication's infusion and subsequent management. Under Medicare, when the anesthesiologist initiates PCA in the recovery room as part of surgical anesthesia time, you can incorporate the initial setup time for the PCA in the total number of anesthesia time units reported. Any PCA services performed after the surgical anesthesia has ended -- including initial setup, subsequent adjustments or follow-up related to this therapy -- are considered routine postoperative pain management, regardless of who performs the service. As such, these services are not separately payable by Medicare for either the surgeon or the anesthesiologist.
 
Parman suggests that most payers don't reimburse PCA because the patient performs the procedure, that is, administers the drug. According to Groudine, "At the facilities I'm familiar with, the surgeon orders PCA management, and it's included in the global surgical fee. In our practice, we do not routinely prescribe PCA because we don't get compensated -- the surgeons do. However, we do bill for initial (99251-99255) and follow-up inpatient (99261-99263) consultations (upon the surgeon's request) for optimizing PCA control for difficult patients. For example, we might recommend alternatives such as using nonsteroidal anti-inflammatory drugs or other adjunctive medications, switching opioids, or changing the method of pain control. We bill this as a consultation because we advise the surgeon on a plan of postoperative management to implement. We do not assume responsibility for patient care; therefore, it would be inappropriate to code for these services using codes for  subsequent hospital care E/M."
 
While PCA has become a standard of care, both Groudine and Parman feel that reimbursement for it is limited to a few commercial carriers. "Perhaps these insurers would accept an unlisted-procedure code, such as 01999 (unlisted anesthesia procedure[s]), or they might tell you what code to use. What is very important is to accurately represent the service provided. CPT coding convention states that it is not correct to use a code that is 'close' to the service provided, but that you report an exact code," Parman says.