Anesthesia Coding Alert

When one Part B Medicare carrier recently alerted anesthesia practices to the top allowed and denied CPT 2007 codes, endoscopy codes 00810 and 00740 made both lists.

In fact, 00810 and 00740 have been the talk nationwide. Let our experts tell you how to submit clean claims for these codes, spot the top reasons for denial and stay on top of which payers may be changing their policies yet again.

Highmark, Pennsylvania's Part B carrier, included 00810 and 00740 on its top allowed and denied lists, which you can find on its Web site at http://www.highmarkmedicareservices.com/partb/reference/denial-reports/2007/cover.html.

Typically you'll use 00810 (Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum) and 00740 (Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum) when you see anesthesia used for esophagogastroduodenoscopies and upper gastrointestinal endoscopies (EGDs), endoscopic retrograde cholangiopancreatographies (ERCPs) and colonoscopies, says Cindy Lane, CPC, CHCC, with Advanced Coding Solutions in Whitehouse, Tenn.

The first thing you need to know is that the EGD code range (43234-43259) and the ERCP services (43260-43272) cross to anesthesia code 00740. And colonoscopy surgical codes 45378-45392 cross to 00810.

You have probably been seeing a lot of 00810 and 00740 lately as anesthesia for endoscopies becomes more commonplace.

"This procedure is growing in popularity, as most people are expecting pain-free endoscopy," says Scott Groudine, MD, an anesthesiologist in Albany, N.Y. "However, it is because of this growth that insurance companies are cracking down on these cases and rejecting claims at a growing rate."

Watch this problem area: Denials are typically due to the diagnosis not meeting a payer's criteria for payment, says Julee Shiley, CPC, CCS-P, CMC, an anesthesia coding consultant in South Carolina. "Some payers make allowances for personal or family history of malignancy for screenings," she says. Payers typically have utilization limits, such as a screening every so many years, and you may see denials if you don't indicate the correct diagnosis.

"Also, if the patient is not of the correct age for the screening and there are no findings or symptoms, this may also be denied," Shiley says.

Tip: Look to the V-code section of ICD-9 for screening and "history of malignancy." For example, report a special screening for colon cancer with V76.51 (Special screening for malignant neoplasms; colon) and a personal history of esophageal cancer with V10.03 (Personal history of malignant neoplasm; esophagus).

Experts note: Local or IV sedation services that the surgeon can normally provide also run the risk of denial.

When you use 00810 and 00740, you know that your diagnosis codes need to be on the money every time.

Good news: In most cases when anesthesia providers are involved, Shiley says, the patient has one or more of the complications or conditions cited in the carrier policy for the use of anesthesia services during routine gastrointestinal endoscopy. Here are some steps our coding experts recommend to be sure you're coding accurately.

"We abstract the anesthesia record, and our providers write the procedure at the end of the case versus what is scheduled," Shiley says. "We also have access to the operative and pathology reports for further clarification."

Snags still crop up with 00810 and 00740, however. Here's a heads-up on how you can overcome them.

"We utilize as many specific diagnoses as possible," Shiley says. She lists the following useful examples:

• patient symptoms

• patient's personal and family history

• special malignancy screening V codes

• chronic and/or comorbid conditions

• patient's physical status to support the necessity of the anesthesia team for this service.

Example: Your payer policy for 00740 and 00810 may state that it considers anesthesiology services medically necessary for patients with conditions such as the following:

• Parkinson's disease (332.0)
• heart conditions (such as 410.xx, Acute myocardial infarction; or 427.41, Ventricular fibrillation)
• mental retardation (318.x)
• seizure disorders (such as 780.39, Other convulsions)

• anxiety (such as 300.0x, Anxiety states).

"We do have to appeal some cases to medical review, but most pay with supporting diagnosis and/or physical status modifiers," Shiley says.

Experts note: Giving an endoscopy "cheat sheet" to anesthesiologists performing the treatment may be the easiest solution. This should contain a description noting which conditions and comorbidities your most commonly used insurers allow.

If the patient does not meet these criteria, the endoscopist should seriously consider conscious sedation. Or -- if the insurer allows -- inform the patient that she may be responsible for the associated charges if the insurer rejects the claim.

Many carriers don't reimburse for anesthesia for every EGD procedure, so some physicians have their patients sign an advance beneficiary notice (ABN) beforehand. This states that the patient will pay for the service -- if the carrier in question accepts ABNs.

"ABNs can be useful for Medicare patients if the physician provides sedation that is not considered medically necessary," Shiley says. "We do not use an ABN for commercial carriers because a noncovered service is typically the patient's responsibility."

Experts note: If you have an ABN, you must submit it at the time of billing -- but don't forget that this can delay processing. If your care is within the carrier's approval policy, you shouldn't file an ABN.

Bottom line: Monitor your carriers' requirements frequently. Never enter into providing anesthesia during EGD procedures without knowing the documentation and reimbursement issues for your carriers.