Anesthesia Coding Alert

Nugget: Anesthesiologists can use modifier -25 to increase reimbursement in the appropriate situations.

Anesthesia coding experts say that if the physician meets the criteria for the key components of the evaluation and management (E/M) service (history, exam, medical decision-making) in conjunction with the procedure and/or service performed and can document that it was a separate service from others performed on the same day, this circumstance may be reported by adding modifier -25 to the appropriate level of E/M service.

The Health Care Financing Administration (HCFA) published a final rule in the Nov. 2, 1999, edition of the Federal Register that outlined the use of modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). Although several months have passed since the ruling went into effect in January 2000, some anesthesia practices still have questions about how this modifier can be used and how it should be documented.

What the Rule Says

According to the rule, it is appropriate to bill modifier -25 when a patients condition requires a significant, separately identifiable evaluation and management (E/M) service above and beyond the usual preoperative and postoperative care associated with the procedure that was performed. E/M service may be prompted by the symptom or condition for which the procedure and/or service was performed.

As such, different diagnoses are not required for reporting the E/M services on the same date a procedure or service was performed. In other words, you may use the same ICD-9 code for both procedural services if it is medically necessary and appropriate, according to Kathy Payne, operations manager with the physician group Anesthesiologists Associated Inc. in Portland, Ore.

However, if it is medically necessary and appropriate to use two different ICD-9 codes , Payne says you should use the two different ICD-9 codes.

Cases When Modifier -25 Can be Billed

Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant in North Augusta, S.C., cites these examples of cases when it is appropriate to use modifier -25 along with the procedure codes:

When an initial patient comes to the office and the anesthesiologist performs and documents an expanded medical history, exam and straightforward medical decision-making (code 99202), and the full workup leads to the decision to initiate a nerve block injection, use code 62311 (injection, single [not via indwelling catheter], not including neurolytic substances, with or without contrast [for either localization or epidurography], of diagnostic or therapeutic substances[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or subarachnoid; lumbar, sacral [caudal]) along with modifier -25.

An established patient comes to the office for his scheduled second injection for pain management (such as a steroid injection, code 62311 ) and complains about new pain symptoms since his last visit unrelated to the pain already being treated. For example, the patient may be initially treated for low back pain (724.2) and now presents with pain radiating down his arm (729.5). The anesthesiologist then asks the patient about the nature of the symptoms, and performs and documents a full work-up exam in conjunction with the nerve block injection.

The appropriate codes would be whichever code from the 99212-99215 evaluation and management series best fits the situation, along with modifier -25 and code 62311 for the diagnosis specific to the initial complaint.

When the physician provides critical care services (preoperative or postoperative) during a global surgical period for a critically ill patient, two requirements must be met in order for these critical care services to be paid: The critically ill patient must require constant attendance of the physician, and documentation must validate that the critical care service is unrelated to the specific anatomic injury or general surgical procedure provided. An ICD-9 code must support the critical care service (such as 518.81, acute respiratory failure, V46.8, dependence on other enabling machines, or 410.9, acute myocardial infarction). Modifier -25 should be appended to whatever code is appropriate for the critical care service thats provided, plus the ICD-9 code supporting the service.

An anesthesiologist is called to place a central venous catheter for a hospital inpatient, and the patient complains of postoperative pain. If the anesthesiologist meets the key components of E/M service, the appropriate E/M code (such as 99232, subsequent hospital care, per day) with modifier -25 could be billed in addition to the catheter placement, code 36489 * (placement of central venous catheter [subclavian, jugular, or other vein] [e.g., for central venous pressure, hyperalimentation, hemodialysis, or chemotherapy]; percutaneous, over age 2).

Other Requirements

Payne points out that modifier -25 should be used only for E/M services. It cannot be used when the E/M service results from a decision to perform surgery, she says. In that case, modifier -57 (decision for surgery) should be used instead.

Modifier -25 is not specifically an anesthesia modifier, she continues. It was designed to indicate an E/M service of significant level that is identifiable as a separate service offered by the same physician on the same day as another procedure or service. Although it is not typically an anesthesia modifier, it can be used by anesthesiologists involved in treating acute or chronic pain patients or in other appropriate circumstances.

Section 15501.1 of the Medicare Carriers Manual has more information about using modifier -25. Payne recommends that coders who want more information check the Medicare Manual or with the ASA, as well as check with their local carriers about other guidelines for appropriate usage.