Anesthesia Coding Alert

Pain-management physicians are sometimes called in to manage postoperative patients who received an epidural catheter during surgery billable with 01996 (daily management of epidural or subarachnoid drug administration). Some carriers reject the code because they mistakenly think that all anesthesia codes are billed based on time 01996 is not.

To get paid on first submission for a billable service, some pain practices drop 01996 and bill a low- to midlevel subsequent inpatient visit (99231-99233) instead. Such billing is inappropriate, coding experts say, unless the physician fulfills the requirements for an E/M visit, which is not normally the case for daily epidural management.
 
In most cases, acute postoperative pain-management services are provided by the surgeon and are included in the procedure's global surgical package. The patient's acute postoperative pain is sometimes severe enough to require consultation or treatment by a pain physician. These specialists may also be asked to implant an epidural catheter to deliver the pain medication postoperatively.
 
"The request from the surgeon to manage the postoperative pain and the medical necessity should be documented in the patient's chart," says Martina Heasley, CPC, an administrator in the department of anesthesia at Stanford University in Stanford, Calif.
 
The pain specialist orders the appropriate medication that is administered to the patient by infusion via the catheter installed during the operation. In the following days, the pain physician checks the patient to inspect the catheter site and to ensure the correct orders have been written and the patient's medication levels are correct.

Coding Services Separately

The catheter placement and the daily medication may be covered separately under certain circumstances. For example, Medicare will pay for the epidural catheter placement and the pain medication if the catheter is placed solely for the purpose of postoperative pain management.

The patient's anesthesia record must state that the catheter was not used to administer anesthesia during the primary procedure.
 
Note: For a detailed discussion on coding and billing of epidural catheter placement, see Pain Management Coding Alert, Second Quarter 2001, Vol. 1, No. 1, page 1.
 
If the surgeon placed the catheter, the pain specialist can bill for postoperative pain-management services beginning the day of the procedure. However, the pain specialist normally begins to bill for the inspection of the catheter site and management of the patient's medication on the day following the surgery.
 
This service should be reported using 01996, says Devona Slater, CMCP, an anesthesia and pain-management specialist in Leawood, Kan. "Unless the patient has another problem that requires the physician to fulfill the criteria of an E/M visit history, exam and medical decision-making it is inappropriate to bill for an E/M services," she says.
 
Many physicians, she notes, write only a few sentences to document rounds performed to check on postsurgical epidurals. Therefore, "The documentation isn't there to justify an E/M, even if the physician thinks otherwise."
 
There are other advantages to using 01996, says Heasley. "When the patient has an epidural and the pain physician checks the catheter and the medication levels, using 01996 distinguishes this visit from other E/M services that may be performed by other physicians, such as the surgeon who performed the procedure. In theory at least, this may make it easier to get paid," she says. Code 01996 has fewer documentation requirements, which is a positive attribute for many physicians. The code also reimburses at a significantly higher rate than a low-level hospital visit.

Payer Problems With 01996

Many private payers, however, have problems accepting 01996. "They see the '0' in front of the code and automatically assume that an anesthesia service has been billed," Heasley says. Because time is a factor when billing most anesthesia services, and no start and end times are provided for postoperative epidural infusion of pain medication, this code is difficult for many carriers to process.
 
As a result, some carriers prefer that an E/M code be billed, particularly a low-level code (i.e., 99231) that reimburses at a significantly lower level than 01996. But this is counterproductive, says Slater.
 
" Code 01996 is a recognized CPT codethat reimburses at a set rate. If a carrier does not understand how 01996 should be processed, it's up to the physician to educate the carrier," she says. "Otherwise, not only are you being reimbursed less, you're also gaming the system."
 
Note: If the carrier specifically requests that an E/M code be used instead of 01996, get the request in writing to avoid subsequent audit problems.
 
However, Medicare says, "If a distinct service separate from [01996] is provided, it should be coded accordingly. Documentation should be presented for case-by-case consideration of coverage of separate services."

Billing an E/M Service

Cases that may permit the billing of an E/M service in place of or in addition to 01996 are infrequent, Slater says. One situation for which an E/M service may be billed instead of 01996 is when the pain physician writes the initial order, because this, if appropriately documented, may include all the components of an E/M service.
 
"If the pain physician performs an evaluation service that includes writing orders for medications, and the documentation reflects that, an E/M visit may, in some cases, be billed," Heasley says.
 
If the physician also treats the patient for a significant, separately identifiable problem in addition to managing the pain medication, modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) should be appended to the appropriate E/M code.
 
Heasley notes that 01996 has documentation requirements, though significantly fewer than what is necessary to bill a midlevel E/M service. "The physician has to identify the patient and note how many postsurgery days have elapsed. He or she has to document the patient's level of pain, as well as whether the patient's medication has been adjusted," she says.
 
Many carriers pay 01996 for three days following the procedure; after that, care may be covered if the physician submits documentation that indicates why additional medication is necessary. Such documentation could include a note from the specialist that explains why more medication is needed and why other pain-management methods (i.e., oral medications or nerve blocks) are not used instead.