Anesthesia Coding Alert

CPT Codes 2003 is coming out next month, but some coders are still trying to understand changes made to the 2002 book. One such area is the section of anesthesia codes for radiological procedures. With eight new codes, eight deletions, and two revisions to the subsection, it's understandable that correctly applying them has presented challenges.

"There have been many advances during the past few years related to interventional radiology (IR) procedures," says Cecelia McWhorter, BA, CPC, a coder with the physician billing agency Comp One Services in Oklahoma City. "Many physicians are performing new procedures such as placement of shunts, coils, filters and stents that will prevent further complications for the patient."

And since an anesthesiologist may be present during these types of procedures, the anesthesia codes needed to be updated to keep up with the changes in this area of medicine.

When Is Anesthesia Being Used?

Tonia Raley, CPC, claims processing team leader with the medical billing firm Medical Information Management Systems in Tuscon, Ariz., has seen an increase in the number of interventional radiology cases that her physicians are providing anesthesia for. "We're providing anesthesia services for procedures such as abdominal aortic aneurysm (AAA), transjugular intrahepatic portosystemic shunt (TIPS), and intracranial transcatheter occlusion or embolization."

Raley and McWhorter give these examples of the types of IR procedures that sometimes correspond to the anesthesia codes for radiology procedures:
 

01905 (Anesthesia for myelography, diskography, vertebroplasty) - This code is somewhat self-explanatory. It is used to report anesthesia during procedures such as 70010 (Myelography, posterior fossa, radiological supervision and interpretation).

01916 (Anesthesia for diagnostic arteriography/venography) - Anesthesia is rarely required for arteriography unless you are treating a child or a profoundly ill or mentally impaired adult. It could be used for procedures such as 36000* (Introduction of needle or intracatheter, vein).

01920 (Anesthesia for cardiac catheterization including coronary angiography and ventriculography [not to include Swan-Ganz catheter]) - This code could correlate to code 36013 (Introduction of catheter, right heart or main pulmonaryartery), but anesthesia is used for these cases in rare circumstances, such as with code 01916.

01922 (Anesthesia for non-invasive imaging or radiation therapy) - Patients undergoing these procedures may need anesthesia because remaining still may be important; the patient does not need to move when high-level radiation treatment is provided. Code 01922 is used when children receive radiation therapy for cancer, for adults who are unable to remain still because of movement disorders (such as severe Parkinson's disease), or for procedures such as 70030 (Radiologic examination, eye, for detection of foreign body).

01924 (Anesthesia for therapeutic interventional radiologic procedures involving the arterial system; not otherwise specified) - This is for arterial therapeutic radiology procedures not included in codes 01925 or 01926 (see below). Embolization of vessels supplying the uterus before a large cancer operation, or of vessels in the upper or lower extremity, is included in 01924, as well as procedures such as 36002 (Injection procedures [e.g., thrombin] for percutaneous treatment of extremity pseudoaneurysm).
 

01925 (& carotid or coronary) - This code applies to stent placement in the carotid or heart vessels, such as for procedures represented by codes 92980 (Transcatheter placement of an intracoronary stent[s], percutaneous, with or without other therapeutic intervention, any method; single vessel) or +92981 (& each additional vessel [list separately in addition to code for primary procedure]).

01926 (& intracranial, intracardiac or aortic) - This could include embolization of a cerebral vessel before surgical treatment of an AV malformation or cerebral aneurysm repair, such as code 61624 (Transcatheter occlusion or embolization [e.g., for tumor destruction, to achieve hemostasis, to occlude a vascular malformation], percutaneous, any method; central nervous system [intracranial, spinal cord]).
 

01930 (Anesthesia for therapeutic interventional radiologic procedures involving the venous/lymphatic system [not to include access to the central circulation]; not otherwise specified) - Anesthesia is so rarely required for a venous repair that McWhorter, Raley and the ACA consulting editors had difficulty thinking of an example to illustrate the code.

01931 (& intrahepatic or portal circulation [e.g., transcutaneous porto-caval shunt {TIPS}]) - As the descriptor suggests, TIPS is the most common example of a procedure reported with code 01931.
 

01932 (& intrathoracic or jugular) - This code may not be used very often, but might apply to procedures such as an embolization of a venous plexus or tumor.

01933 (& intracranial) - This code is used for anesthesia during procedures such as 37195 (Thrombolysis, cerebral, by intravenous infusion).

New Codes Mean New Challenges

Although coding for anesthesia during IR procedures is somewhat easier with the new codes, McWhorter and Raley agree that there are still obstacles to overcome.

"One particular challenge with coding for these cases is determining whether the procedure involved the arterial system or the venous/lymphatic system," Raley says. She notes that main descriptions of each set of these codes read a little differently. Codes 01924-01926 are for procedures involving the arterial system, while codes 01930-01933 are for procedures involving the venous/ lymphatic system.

"Another challenge is determining which anesthesia code to use," Raley adds. Occasionally, a coder must ask the physician to clarify what procedures were performed and what techniques were used.

For example, the anesthesiologist may write "aortic aneurysm repair" in the procedure notes. That doesn't answer the question of whether it was an open or interventional procedure, which is important to know when coding for the anesthesia. An abdominal, or open, approach to repairing an aortic aneurysm is coded as 35081 (Direct repair of aneurysm, pseudoaneurysm, or excision [partial or total] and graft insertion, with or without patch graft; for aneurysm, pseudoaneurysm and associated occlusive disease, abdominal aorta) while an interventional radiographic placement of an aortic endograft is reported with code 34800 (Endovascular repair of infrarenal abdominal aortic aneurysm or dissection; using aorto-aortic tube), 34802 (& using modular bifurcated prosthesis [one docking limb]) or 34804 (& using unibody bifurcated prosthesis). The appropriate anesthesia code will depend on how the repair was performed.

If you're confused about how the procedure was performed and whether the IR codes should be reported instead of other anesthesia codes, Raley suggests checking the physician's specialty. Many surgeons do not have interventional procedure privileges at the facility where they practice, and most radiologists do not have full surgical privileges. So, if a vascular surgeon is listed as the physician performing an embolectomy, he probably did not use an IR approach.

Notes about the equipment used or other charges during the procedure can also point you to whether it was an IR or open procedure.

A third challenge with coding for these cases lies with carriers who may balk at reimbursing anesthesia for IR procedures. In McWhorter's opinion, "This isn't an unusual problem when new procedures are performed, such as anesthesia during IR procedures. The carrier must realize that these are treatments for medical problems, not procedures done on a trial or experimental basis, before they'll reimburse for the anesthesia."

But McWhorter also acknowledges that some problems with coding for IR procedures also lie with the physicians and coders themselves. Many physicians spend time staying current with medicine, but most medical journals rarely - if ever - address coding. Coders must help educate the physicians in these areas.

McWhorter recommends a proactive approach in dealing with this challenge. Speak with the carriers before filing claims, since carrier-specific rules often come into play (especially when new CPT codes are involved). Talk with the physician performing the procedure or with the anesthesiologist to learn details about the case that will help you code it correctly.

And finally, submit the anesthesia record and operative reports when filing claims for new procedures such as anesthesia during IR sessions to help facilitate reimbursement.