Anesthesia Coding Alert

Question: A 67-year-old Medicare patient is having total knee arthroplasty at our hospital, and the surgeon has requested that the anesthesia department provide an adductor canal block for postoperative pain. How do we code these services for the anesthesiologist who is personally performing anesthesia for the total knee and performing the block? Do we need to file separate claims? What kind of documentation is required?

Texas Subscriber

Answer: As long as the anesthesiologist used the block for postoperative pain and not as the mode of anesthesia, you may report both services separately and include them on the same claim.

Surgical anesthesia: For the anesthesia for the total knee surgery, report 01402 (Anesthesia for open or surgical arthroscopic procedures on knee joint; total knee arthroplasty) and append modifier AA (Anesthesia services performed personally by anesthesiologist).

Both the American Society of Anesthesiologists (ASA) Relative Value Guide^® (RVG™) and Medicare assign 7 base units to 01402.

Post-op block: Report 64447 (Injection(s), anesthetic agent(s) and/or steroid; femoral nerve) for the adductor canal block (the adductor canal is a passageway for structures in the thigh). Medicare National Correct Coding Initiative (NCCI) edits bundle 64447 into 01402. To explain the service was separate from the anesthesia provided for the surgery, you should append a modifier such as XU (Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service).

Although NCCI also allows modifier 59 (Distinct procedural service), XU is more descriptive and gives “greater reporting specificity in situations where you used modifier 59 previously” (www.cms.gov/files/document/ mln1783722-proper-use-modifiers-59-xepsu.pdf). Medicare recommends using the X{EPSU} modifiers instead of modifier 59 whenever possible, and to only use modifier 59 if no other more specific modifier is appropriate.

If the anesthesiologist uses and properly documents ultrasound guidance, you may report 76942 (Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation) with modifier 26 (Professional component) appended.

Remember: CPT^® 2023 will add “including imaging guidance, when performed” to the descriptors for 64415-64417 and 64445-64448. That means you will no longer report ultrasound guidance (such as 76942) or other types of imaging guidance separately when the provider uses that guidance on dates of service Jan. 1, 2023, and later.

Documentation help: Both the ASA “Statement on Reporting Postoperative Pain Procedures in Conjunction With Anesthesia” (www.asahq.org/standards-and-guidelines/ statement-on-reporting-postoperative-pain-procedures-in-conjunction-with-anesthesia) and Medicare National Correct Coding Initiative Policy Manual, Chapter 2 (www.cms.gov/ files/document/chapter2cptcodes00000-01999final11.pdf), offer excellent resources for documentation.

Documentation should include the surgeon’s request for the post-op block and explain the five “Ws”:

• Who provided the service(s)?
• What was the service(s)? (For postoperative pain management, watch for a chief complaint/diagnosis and ultrasound guidance with report and saved image, if applicable.)
• When exactly was the service(s)? (Although post-op block time is not included in the anesthesia time reported, the time must be clear to ensure no double dipping. You do not need to deduct the time if the anesthesiologist places the block intraoperatively.)
• Where exactly was the injection/catheter? (Documentation should include specific anatomical terms.)
• Why was the service(s) provided? (Routine post-op pain management is included in the surgeon’s global service, so surgeons must request services that they are not able to provide to the patient. Preferably, the request should be in writing.)