Anesthesia Coding Alert

When billing for services outside the global anesthesia fee, some coders might shy away from separate E/M codes for fear that they bring extra scrutiny. But there are times when circumstances merit billing for additional services, and not using E/M codes when appropriate can cost an organization its fair share of reimbursement.

By familiarizing yourself with situations that qualify for separate E/M billing and knowing how to select the most appropriate code for services, you can help capture some charges that might otherwise be overlooked. Keep the following questions in mind when you're faced with E/M coding.

Are You Meeting the Requirements?

The first step in knowing whether E/M codes can be used is to learn the requirements for consults. One way some coders remember E/M criteria is by noting the three R's request, render and respond. All of these criteria must be met before time spent with a patient can be coded as an E/M service:
 

The request for the anesthesiologist's consult must be in writing in the patient's chart.

The anesthesiologist renders service to the patient.

The anesthesiologist responds to the requesting physician in writing with the exam results, recommendations for further treatment, and other pertinent information.

Documentation clarifying why a consult was performed instead of a routine pre-op exam must be included in the anesthesiologist's notes. Such documentation should include the length of time before surgery and why the request was made.

For instance, a patient over age 70 with multiple medical problems (cardiac, hypertension, history of bad response to anesthesia, hypothyroid, etc.) is scheduled for surgery. The surgeon requests an anesthesia consult to determine whether the procedure can be performed under MAC (monitored anesthesia care) or regional anesthesia. Billing the anesthesiologist's time with the patient as a separate consult rather than including it as part of the routine preoperative exam is appropriate because he is making a higher-level decision than in a normal preoperative situation.

Documentation of the E/M visit must also include information regarding the patient's medical history and physical examination as well as the anesthesiologist's medical decision-making. The consultation's level of service depends on whether the physician meets or exceeds CPT guidelines for each of these components (history, exam and medical decision-making).

Is the Preoperative Consult Billable?

"Typical preoperative evaluations for the purposes of undergoing an anesthetic cannot be billed as consults," says Lewis Woodell, director of reimbursement and compliance in the anesthesia billing office of Summit Healthcare in Fort Worth, Texas. "However, consults on potential surgical candidates that are done more than 72 hours prior to surgery might be billable."

Consults for certain services are billable regardless of the time frame. For example, if the anesthesiologist evaluates a patient prior to transplant surgery, or if the surgeon is unsure whether to grant the patient's request for a local or spinal anesthetic during the procedure, the consult is billable.

"If the anesthesiologist is asked to render an opinion of whether the patient is an acceptable candidate for a procedure under anesthesia, and the history, exam and medical decision-making is documented properly, it would be appropriate to bill for a consultation," says Bev Gillespie, billing specialist II with PSG Billing and Collection in Milwaukee. "Again, the three-R's rule must be met, and the level of service must meet all three components of the code being used."

In addition to meeting the general E/M criteria outlined above, Woodell says that their physicians are instructed not to use the facility's Anesthesia Preoperative Evaluation sheet as their consult note if the visit will be billed as a consult. The consult should also not be labeled as an "anesthesia pre-op consult," otherwise it won't be separately billable. All documentation of the E/M criteria is submitted along with a face sheet for coding and billing the service.

All facilities require patients to be evaluated by an MD prior to inpatient or outpatient surgery, and most facilities require that only MDs admit patients for treatment. When this is the case, the anesthesiologist may sometimes be asked to evaluate the patient and serve as the MD clearing him for surgery.

For example, podiatrists have the credential DPM, not MD. In facilities such as Summit Healthcare, podiatry is a specialty that cannot clear a patient for surgery because podiatrists are not MDs. Because of this, Woodell says, the anesthesiologist is often called to consult with the patient and complete the necessary paperwork for admission. It is a billable service for referral from a podiatrist, assuming that all requirements for billing consultation codes are met. Use the appropriate consultation code for a preoperative consultation for a new or established patient from the series 99241-99245 for outpatient consultations or 99251-99255 for initial inpatient consultations.

In a similar situation, Woodell says, his facility requires that a patient history and physical (H&P) conducted by an MD be included in the patient's chart. The anesthesiologists "do these in about 95 percent of the cases when the surgeon is a podiatrist," he says. "It's usually done the day of surgery, and a form separate from the anesthetic record is completed for the facility."

Some coders consider this service to be included in the global anesthesia fee because the procedures performed by podiatrists are often considered to be minor rather than major, but those same coders acknowledge that the service could be separately billable if the case is complicated by extremely poor health and if the anesthesiologist's decision may affect the surgical outcome. (The same applies to dental procedures, which fall into the same category as podiatry procedures in terms of needing an MD's evaluation and admission.)

Do Pain Management Services Qualify?

As the field of pain management continues to grow, anesthesia providers often find it appropriate to bill E/M services. Pain management services that merit E/M coding include postoperative pain management, ongoing chronic pain management, and evaluations/consults for possible medication pump placement for chronic pain and continuous pain management care.

"A consultation may be appropriate to bill when another physician requests an anesthesiologist to see a patient to determine if a course of pain management (either acute or chronic) may be appropriate for the patient," Gillespie says. "Once the anesthesiologist begins to treat a patient, he is no longer acting as a consultant, but then subsequent hospital visits or established patient visits would be appropriate in addition to any procedures being performed."

For example, a patient with a very low pain threshold has an open chest procedure, such as a lung resection. The anesthesiologist (usually a pain management subspecialist) performs a consult and recommends to the surgeon how to treat the patient's pain. He may begin those treatments under the guidelines of a consult and write a note to the surgeon regarding the patient's care. If the surgeon then asks the anesthesiologist to "treat the patient for pain control" because he feels that this is beyond his control as a surgeon, then the pain management physician can continue to care for the patient.

Although follow-up pain control is typically included in the surgeon's care, the patient sometimes has pain that might be better handled by someone trained in pain management. Anesthesiologists often use pain management code 01996 (Daily management of epidural or subarachnoid drug administration) to report a patient's follow-up pain management after surgery, such as hip replacement or other major procedures. This code is appropriate if the epidural was placed for postoperative pain management and if the anesthesiologist is seeing the patient each day.

But many carriers prefer an appropriate E/M code rather than 01996, Gillespie says. "Most carriers feel that this follow-up care is part of postoperative management, and the surgeon is already being paid for that. If the anesthesiologist is going to get paid for this code, he should probably negotiate getting a portion of the surgeon's payment.

"Instead of using 01996, most carriers want the anesthesiologist to use an E/M code in its place," Gillespie says. "The physician really is providing a certain level of E/M service anyway, so it's appropriate. You just need to be sure that whatever the physician documents ties in with a particular E/M code level that fits."

The appropriate E/M codes for this situation are in group 99231-99233, dealing with three levels of subsequent hospital care.

What About Cancelled or Postponed Cases?

It's happened to every anesthesia provider at one time or another a case is cancelled or postponed after at least part of the anesthesia workup has been completed. Sometimes the work is still rolled into the anesthesia fee when the case takes place later, but sometimes it isn't. How do you distinguish between including it with the global fee later, charging an E/M service for it or writing it off altogether? And how does modifier -53 (Discontinued procedure) come into play?

Basically, you can bill an appropriate E/M code if the case is canceled between the anesthesiologist's preoperative evaluation and induction, and the case is not rescheduled within the next few days. (Many coders use five days as a guideline and will bill three base units for the canceled procedure plus whatever time units apply.) If the case is canceled and rescheduled soon, many anesthesiologists include their work in the global anesthesia fee and do not bill separately for the initial work. You cannot bill the preoperative service with modifier -53 unless the patient was induced and put to sleep before the case was canceled.

The Bottom Line for Reimbursement

Knowing when to use E/M codes appropriately is important, but the bottom line for providers is whether they'll be reimbursed for the service. Success on that front can vary among carriers.

"We find that most carriers will not pay for E/Ms with procedures, even if we use modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) or -57 (Decision for surgery)," Gillespie says. "They will request documentation to determine if the E/M service was medically necessary in addition to any procedure performed on the same day."

Because of this, some anesthesiologists opt to bill E/M services only when unusual circumstances help bolster their chances for reimbursement. As with many other reimbursement situations, some carriers pay, some ask for documentation to verify the claim, and some simply deny the service.