Anesthesia Coding Alert

Medicare will pay for placement of an epidural catheter in addition to administration of anesthesia if the catheter is placed solely for postoperative pain management, says Tonia Raley, CPC, claims processing team leader for Medical Information Management Solutions, a medical billing service in Phoenix. The patients anesthesia record must indicate, however, that the catheter administered no continuous anesthetic during the procedure.

Physicians place epidural catheters for postoperative pain management because patients undergoing certain types of surgery (e.g., thoracic) recover more quickly they ambulate sooner and have shorter hospital stays when postoperative pain is controlled by continuous infusion of pain medication.

Coding the Catheter Placement

An epidural catheter may be introduced at four sites along the spine. CPT Codes 2000 introduced two codes corresponding to these areas. Placement of a cervical or thoracic catheter is coded 62318 (injection, including catheter placement, continuous infusion or intermittent bolus, not including neurolytic substances, with or without contrast [for either localization or epidurography], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or subarachnoid; cervical or thoracic), and lumbar or sacral introduction is coded 62319 ( lumbar, sacral [caudal]). Postoperative management of the catheters is coded 01996 (daily management of epidural or subarachnoid drug administration).

Modifier -59 (distinct procedural service) should be appended to the appropriate epidural catheter placement code if documentation shows that the catheter is for pain management and is therefore distinct and separate from the general anesthesia used for the procedure, Raley says.

For example, a pediatric patient undergoes a pancreatectomy. The general anesthesia is reported as an intravenous-inhalant combination, and a lumbar catheter is placed. At the start of surgery, 4 cc of bupivicaine is delivered via the catheter to test the catheters viability. The surgery lasts over six hours, during which no additional medication is injected into the catheter. An hour before the surgery ends, a second, smaller dose of medication is pushed through the catheter, followed by a third small dose at the end of surgery.

In the recovery room, the physician (either a pain management specialist or the surgical anesthesiologist) writes orders for an epidural medication cocktail. The recovery room nurse fills the order and hangs the bag of medication to begin a continuous infusion via the previously placed catheter. The physician follows up on subsequent days to ensure the medication levels are adequate and orders are written.

This is an excellent example of when the epidural procedure is separately billable in addition to the global anesthesia care, says Martina Heasley, CPC, an administrator in the department of anesthesia at Stanford University in Stanford, Calif.

Code 62319 should be billed because a lumbar catheter was placed. Modifier -59 should be appended to indicate the catheter placement is separate and distinct from the general anesthetic for the surgery, Heasley says.

Note: The primary anesthesia code is for delivery of global anesthesia for the pancreatectomy (48140). The anesthesiologist would bill CPT 00794 (anesthesia for pancreatectomy, partial or total) followed by 62319-59.

In addition, CPT 01996 may be billed for subsequent days of care but may not be separately billed on the surgery date.

Note: If the epidural catheter is placed by the surgeon, but the anesthesiologist performs the pain management delivery, 01996 is payable on the same day of surgery.

Supporting documentation should include the anesthesia record, which indicates that general anesthetic was administered via IV and/or inhalant (not through the epidural catheter).

In most cases, postoperative pain management is generally part of the global surgical package and should be managed by the surgeon, Raley says. In certain circumstances, however, the surgeon may request that the anesthesiologist provide care for the postoperative pain management. In those cases, ensure that the request from the surgeon and the medical necessity is clearly documented in the medical record.

Raley also recommends including diagnosis code V58.49 (other specified aftercare following surger) on the HCFA 1500 form to help get the claim processed.

Know When Catheter Placement Isnt Payable

If the catheter is used during the surgery to administer anesthesia, either in addition to or in place of general anesthesia, the placement is bundled into the global anesthesia service and may not be separately billed, Heasley explains.

Medicare only pays for placement if the catheter is implanted for postoperative pain management. Heasley says. However, Medicares billing guidelines do not always correspond to medical practice and that can cause trouble.

When Heasley looks at the anesthesia record, it may show the physician testing medications through the catheter to make sure the epidural is working correctly. Tests like this, she says, are fine. But sometimes, physicians also use the epidural to deliver supplemental anesthetic during surgery. Once the catheter is in place, physicians may use it to deliver alternate anesthetics. That way, the patient doesnt require as much general anesthetic. The result, they say, is a better outcome for the patient, Heasley says.

Physician reimbursement, however, will not be so positively affected. Heasley says her rule of thumb is, If the catheter delivers continuous anesthetic during surgery, its placement is not separately billable, even if it also is used after surgery for pain management. Carriers will not reimburse the placement of a catheter for the following:

1. When the Catheter Is Used to Deliver a Regional Block or Continuous Anesthetic. The catheter is placed. A single injection creates a regional block of a continuous drug infusion and provides anesthesia. No other anesthetic is used. The patients vital signs are closely monitored just as they would be with general anesthesia during monitored anesthesia care (MAC). In this situation, even though the catheter might eventually be used to deliver postoperative pain medication, it was placed for administration of anesthetics. You could bill the catheter procedure only or you could bill the global anesthesia. I prefer to bill the base plus time for global anesthesia and add modifier -QS [monitored anesthesia care service] to report MAC, Heasley says.

Note: Modifier -QS is a level II HCPCS modifier.

2. Medications Administered by Catheter Supplement General Anesthesia. The patient is placed under general anesthetic, but additional anesthesia a different medication with different characteristics is delivered through the epidural catheter. As a result, the catheter placement is part of the global anesthesia service, even though it may also serve to deliver postoperative pain medication later. This is another circumstance where one could bill only the epidural or only the anesthesia. I bill the service with the higher value, Heasley says.

Physicians often argue that they would not have placed the catheter except for postoperative pain management, and that they only used the catheter to improve the anesthetic outcome because it was there already, Heasley notes. Unfortunately, carriers do not pay according to this line of reasoning.