Anesthesia Coding Alert

Check these 3 areas before coding your next claim

Performing eye surgery can be quick and easy (comparatively speaking) for surgeons, but coding your anesthesia providers' work is never cut-and-dried.

A physician administers a pain block before the eye surgery begins, and a physician or other qualified anesthesia professional monitors the patient during the procedure. Knowing who is involved with each portion of the procedure from an anesthesia standpoint ensures you code correctly.

Understand What's Happening 

"Facilities see a high volume of these cases performed almost exclusively as outpatient procedures," says Darlene Ogbugadu, CPC, an anesthesia coding supervisor with Northwestern Medical Faculty Foundation in Chicago. "They usually involve the administration of a local anesthetic in addition to systemic sedation and blocks administered by the anesthesiologist."

Diagnoses leading to eye surgery can include cataracts (366.xx), glaucoma (365.xx), strabismus (378.xx) and retinal detachment (361.xx).

"Retrobulbar blocks are useful methods of achieving anesthesia for intraocular and orbital surgeries," Ogbugadu adds. "These blocks are good alternatives to general anesthesia when general anesthesia is undesirable or contraindicated."
 
Case 1: Anesthesiologist Places the Block, CRNA Observes 

Some facilities prefer to have the anesthesia team handle all aspects of eye surgery anesthesia. If so, the anesthesiologist sometimes places the initial block but assigns a CRNA to observe the case once it begins.

In years past, some coders in this situation reported the retrobulbar block with 67500 (Retrobulbar injection; medication [separate procedure, does not include supply of medication]) in addition to the procedure's anesthesia. But problems can arise with this stance once the anesthesiologist hands off the care to the CRNA, so many of today's coders don't code the block itself.

"Most carriers consider billing the retrobulbar blocks in addition to the anesthesia time and base units as bundling and not payable," Ogbugadu says. "We do not bill for the block."

Instead, only report the correct procedure code:

• 00140 -- Anesthesia for procedures on eye; not otherwise specified
• 00142 -- ... lens surgery
• 00144 -- ... corneal transplant
• 00145 -- ... vitreoretinal surgery.

Add MAC: You should also report the appropriate MAC (monitored anesthesia care) modifiers for the case, depending on your carrier's guidelines. Always append modifier QS (Monitored anesthesia care service) to the code, and add modifier G9 (Monitored anesthesia care for patient who has history of severe cardiopulmonary condition) when appropriate.

Note: MAC modifier G8 (Monitored anesthesia care [MAC] for deep complex, complicated or markedly invasive surgical procedure) applies to some cases but shouldn't come into play with eye surgeries unless something about the procedure merits a "markedly invasive" designation.

"Our surgeons prefer MAC anesthesia for these cases because 80 percent of our cases are aged patients," says Vicki Embich, a coding supervisor with West Florida Medical Center Clinic in Pensacola. "This allows closer observance of their personal health issues."

Case 2: Surgeon Places the Block, Anesthesiologist Monitors the Case 

A more common approach for eye procedures in some facilities -- and the arrangement many carriers prefer -- involves the surgeon placing the initial block and the anesthesia professional monitoring the case. Embich's group always handles cases this way.

"The anesthesiologist provides medical supervision," Embich says. "We run four rooms at a time."

Because the anesthesiologist works in a supervising capacity, be sure to include the correct modifiers on each provider's claim (in addition to modifier QS):

• QK (Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals) for the anesthesiologist

• QX (CRNA service: with medical direction by a physician) for the CRNA.

"Each insurance company handles reimbursement in its own way," Embich says. Verify that your carrier requires modifiers QK and QX before submitting them with your claims.

Embich predicts a trend in this direction for retrobulbar blocks, which means you need to be up-to-speed with your carriers' preferences. "As time goes on, this will probably become CRNA-allowed only when MAC is involved," Embich says.

Case 3: Anesthesiologist Is Involved Throughout the Case

In a third possible scenario, the anesthesiologist participates from start to finish: He administers the initial block and then administers MAC himself during the case.

Ogbugadu and Embich agree that having an anesthesiologist involved throughout the case is the rarest scenario they see. If your anesthesiologist handles the entire eye surgery procedure, keep these things in mind when you have to code the case:
 
• Expect discontinuous time. The anesthesiologist will place the block, leave the room while the block takes effect, and return in time for the procedure. Because he's not with the patient from start to finish, you'll need to watch your time units. Calculate the time he spent placing the block and the time spent during the procedure for the  total minutes.

• Code for the procedure, not the block. Your anesthesiologist places the block in preparation for the procedure, not as a separate pain management service. Therefore, you only code for the eye procedure instead of the procedure and block. You should incorporate the time spent placing the block, however, when you calculate the anesthesiologist's total time units.

Know Your Carrier and Surgeon Preferences

When cases involving retrobulbar blocks cross your desk, check the carrier's stance before automatically coding your anesthesiologist's service -- even if he placed the initial block. Some carriers bundle the retrobulbar block into the ocular surgery payment, but others consider the block to be local anesthesia and bundle it with the anesthesia code. Knowing the carrier's guidelines will help your anesthesiologist and the surgeon determine the best approach.

"The surgeon's preference for patient comfort, surgical outcome and ease of performing the procedure do influence having an anesthesiologist involved with the patient's care," Ogbugadu says. "Having an anesthesiologist involved does increase the cost, but it produces greater patient satisfaction."