Anesthesia Coding Alert

Studying up now could reduce denials in January for pain management, too.

CPT Codes 2009 has plenty of updates for anesthesia coders to grasp, but these changes are designed to help make your job easier.

"Two new anesthesia codes could help streamline your reporting processes," says Kelly Dennis, MBA, CPC, ACS-AP, of Perfect Office Solutions Inc. in Leesburg, Fla.:

1. 00211 -- Anesthesia for intracranial procedures; craniotomy or craniectomy for evacuation of hematoma

In 2008, the crosswalk options for these intracranial procedures were either 00210 (Anesthesia for intracranial procedures; not otherwise specified) with a base of 11, or 00218 (Anesthesia for intracranial procedures; procedures in sitting position) with a base of 13. "The new code is a one unit reduction in 2009, unless the patient is in sitting position," says Dennis.

2. 00567 -- Anesthesia for direct coronary artery bypass grafting; with pump oxygenator

Don't miss: CPT 2009 added a semicolon to the descriptor to allow 00566 (Anesthesia for direct coronary artery bypass grafting; [CABG] without pump oxygenator) to become a parent code to code 00567, Dennis points out. The addition of the new CABG code with pump oxygenator results in a two unit reduction in 2009, unless the procedure involves both coronary and valve work.

New Codes Arrive for Plantar Nerves and Back Pain

CPT adds a couple of plantar nerve 64xxx codes and several performance measure codes for the new back pain clinical condition for 2009.

1. 64455 -- Injection(s), anesthetic agent and/or steroid, plantar common digital nerve(s) (e.g., Morton's neuroma)

This new code is important because of its specificity -- it's clearer than using 64450 (Injection, anesthetic agent; other peripheral nerve or branch). Plus, some Medicare carriers, such as Noridian,-had issues with providers reporting 64450 for an injection of Morton's neuroma and wanted you to use 64999 (Unlisted procedure, nervous system), says Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, of MJH Consulting in Denver. The AMA directs providers to report 64455 one time only, regardless of the number of injections performed during a session.

2. 64632 -- Destruction by neurolytic agent; plantar common digital nerve

Like 64455, this code adds more specificity than using 64640 (Destruction by neurolytic agent; other peripheral nerve or branch), Hammer points out.

Pain Management Codes Get a Boost

Various Category II codes have been created for the back pain performance measure:

• 0525F-0526F -- Visit for episode

• 1130F-1137F -- Back pain assessment

• 2040F -- Physical examination on the date of the initial visit for low back pain performed, in accordance with specifications

• 2044F -- Documentation of mental health assessment prior to intervention (back surgery or epidural steroid injection) or for back pain episode lasting longer than six weeks

• 3330F -- Imaging study ordered

• 3331F -- Imaging study not ordered

• 4240F -- Instruction in therapeutic exercise with follow-up by the physician provided to patients during episode of back pain lasting longer than 12 weeks

• 4242F -- Counseling for supervised exercise program provided to patients during episode of back pain lasting longer than 12 weeks

• 4245F -- Patient counseled during the initial visit to maintain or resume normal activities

• 4248F -- Patient counseled during the initial visit for an episode of back pain against bed rest lasting 4 days or longer.

These make for a performance measure with true applicability for pain management, Hammer says, adding that this measure is one Medicare will likely track with the proposed 2009 HCPCS codes G8493 (I intend to report the back pain measures group) and G8502 (All quality actions for the applicable measures in the back pain measures group).

Don't Miss This 64416 Change

Here's a quick rundown of how four of your common anesthesiology and pain management coding relative value units (RVUs) will change.

• 64416 -- Injection, anesthetic agent; brachial plexus, continuous infusion by catheter (including catheter placement) (RVU change from 4.79 to 2.48)

• 64446 -- Injection, anesthetic agent; sciatic nerve, continuous infusion by catheter (including catheter placement) (RVU change from 4.55 to 2.44)

• 64448 -- Injection, anesthetic agent; femoral nerve, continuous infusion by catheter (including catheter placement) (RVU change from 4.14 to 2.16)

• 64449 -- Injection, anesthetic agent; lumbar plexus, posterior approach, continuous infusion by catheter (including catheter placement) (RVU change from 4.08 to 2.40).

"All four of these codes had the phrase 'including daily management for anesthetic agent administration' deleted, which is a big change," Hammer says. Even though this may seem like bad news, there is a silver lining to these clouds -- these four codes change from having a 10-day global period in 2008 to a zero-day global period effective Jan. 1, 2009. The RVU decrease is due to the elimination of the post-procedure follow-up visits.

What this means for you: If your provider needs to see the patient for pain management on subsequent following days, they can separately report the appropriate E/M service code for the visit.

Don't Count on 0027T

Code 0027T (Endoscopic lysis of epidural adhesions with direct visualization using mechanical means [e.g., spinal endoscopic catheter system] or solution injection [e.g., normal saline] including radiologic localization and epidurography) is no longer a Category III code. In fact, it no longer exists, come January.

"Perhaps this code 'timed out' its Category III status, and frequency usage data did not support converting to a valid Category I code," Hammer muses. The original effective date for this code was July 1, 2002. "Providers will need to go back to using 64999 (Unlisted procedure, nervous system) if they are using the endoscope for epidural lysis of adhesions," Hammer says.

The key here is the use of an endoscope, as there still remains valid CPT Codes for epidural lysis of adhesions: 62263 (Percutaneous lysis of epidural adhesions using solution injection [eg., hypertonic saline, enzyme] or mechanical means [e.g., catheter] including radiologic localization [includes contrast when administered], multiple adhesiolysis sessions; 2 or more days) and 62264 (. . . 1 day). But you should not use those to report the endoscopic technique.

Tip: CPT deleted an instruction to use 0027T for endoscopic lysis of epidural adhesions, which CPT 2008 included in the "Injection, Drainage or Aspiration" subsection guidelines in the "Spine and Spinal Cord" section of Surgery/Nervous System.

Be Sure You Catch 62267, 646xx Changes, Too

The new code 62267 (Percutaneous aspiration within the nucleus pulposus, intervertebral disc, or paravertebral disc, or paravertebral tissue for diagnostic purposes) is in place for 2009. Since you'll have 62267 for diagnostic aspiration, CPT 2009 revises discectomy code 62287 to clarify its use. In 2008, the code descriptor reads, "Aspiration or decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method, single or multiple levels, lumbar (e.g., manual or automated percutaneous discectomy, percutaneous laser discectomy)." The 2009 version deletes "Aspiration or." It also adds a note not to report 62287 with 62267.

How it helps: The clinical example for 62287 involved therapeutic aspiration of a bulging disc for decompression--- not diagnostic aspiration--- but the code descriptor wasn't really clear about this. The 2009 change helps clear up confusion about proper 62287 use.And don't miss a helpful note in the section guideline for "Destruction by Neurolytic Agent (e.g., Chemical, Thermal, Electrical or Radiofrequency)" in the 646XX area of Surgery/Nervous System.

New note: "For therapies that are not destructive of the target nerve, such as pulsed radiofrequency, use 64999," Hammer quotes.