Anesthesia Coding Alert

Question: Could you assist with this anesthesia question? A 56-year-old patient had an open posterior decompression, C5 through T1, with instrumentation. The case was medically directed along with one other case, and the CRNA documented a Swan-Ganz and a central line placed by the anesthesiologist. How should we report each of the anesthesia providers’ services?

Florida Subscriber

Answer: Assuming documentation supports the medically directing physician’s presence as required by the insurance carrier and the anesthesiologist threaded the Swan-Ganz using the existing central line, the claims should be as follows.

The anesthesiologist should report:

• 00670 (Anesthesia for extensive spine and spinal cord procedures (eg, spinal instrumentation or vascular procedures)) with modifier QK (Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals)
• 93503 (Insertion and placement of flow directed catheter (eg, Swan-Ganz) for monitoring purposes)

The CRNA should report:

• 00670 with modifier QX (CRNA service: with medical direction by a physician)

Rationale: You indicated the spine procedure involved instrumentation, so 00670 is the correct code for the anesthesia service. Both Medicare and the American Society of Anesthesiologists (ASA) Relative Value Guide^® assign a base value of 13 units for this code.

Avoid reporting these similar codes that do not specify instrumentation: 00600 (Anesthesia for procedures on cervical spine and cord; not otherwise specified), which applies to anesthesia for an open procedure on the cervical spine and cord, and 00620 (Anesthesia for procedures on thoracic spine and cord, not otherwise specified), which applies to an open procedure on the thoracic spine. Both procedures have a base unit value of 10.

If the anesthesiologist used the central line (36556, Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older) to thread the Swan-Ganz (93503, Insertion and placement of flow directed catheter (eg, Swan-Ganz) for monitoring purposes), you should report only the Swan-Ganz.

Here’s why: Many payers follow Medicare’s rule that you should not report 93503 with 36556 for insertion of a single catheter (Medicare’s National Correct Coding Initiative Policy Manual, Chapter XI, Section I.25). The ASA has a similar rule in their standards and guidelines (www.asahq.org/standards-and-guidelines/statement-on-intravascular-catheterization-procedures).

Code 93503 should be on the medically directing physician’s claim because the provider who performs the service bills it.

If there is documentation to support the medical necessity of two separate lines, and the anesthesiologist did not thread the Swan-Ganz through the existing central line, you may report both separately.

Don’t forget: Based on the patient’s age, as long as they are not a Medicare patient and if there is documentation of the patient’s physical status, you may be able to report a physical status modifier. Some insurers (not Medicare) pay additional units when patients have a higher-acuity status (such as severe disease).