ED Coding and Reimbursement Alert

You could be coding more deep sedation services this year in the ED, thanks to recent changes. Your claims' accuracy will depend on careful documentation of the duration and level of consciousness achieved. Read on for expert advice on modifier use and payer regulations dealing with anesthesia.

What's driving the trend: The advent of newer sedation drugs, particularly propofol, have led to greater sedation effectiveness and less recovery time for the patient after deep sedation, thus making the services a better fit in the ED. Increased residency training in deep sedation protocols have also contributed to the increase.

Green light from CMS: CMS issued a policy clarification in January 2011 that clearly recognized that it is acceptable to CMS for emergency physicians to provide all levels of sedation. CMS stated that "Emergency Medicine-trained physicians are uniquely qualified to provide all levels of analgesia/sedation and anesthesia (moderate to deep to general)."

Take This Definition Refresher

CPT^® clearly defines what Moderate Sedation is and what it is not, says Stacie Norris, MBA, CPC, CCS-P, Director of Coding Quality Assurance for Medical Management Professionals in Durham, NC. From CPT^®, "Moderate (conscious) sedation is a drug induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. Moderate sedation does not include minimal sedation (anxiolysis), deep sedation or monitored anesthesia care (00100-01999)."

Coding tip: To accurately bill these services, you'll need ED providers to document the patient's level of consciousness throughout all anesthesia services, says Norris. CPT^® directs coders to the Anesthesia Section of CPT^® to code deep anesthesia or monitored anesthesia care.

The CPT^® Anesthesia section guidelines state that the Anesthesia codes include the usual preoperative and postoperative visits, the anesthesia care during the procedure, the administration of fluids and/or blood and the usual monitoring services such as EKG, temperature, blood pressure, pulse oximetry, capnography and mass spectrometry.

Modifier 47 alert: When coding regional or general anesthesia services provided by the same physician performing the service for which the anesthesia is administered, CPT^® directs the use of modifier 47 (Anesthesia by Surgeon), to be appended to the basic service. Norris adds that you should check with individual payers for their policy on the use of this modifier.

Heed Time, Patient Status: Careful reporting of anesthesia time is critical to the coding and documentation of these services. Per CPT^®, anesthesia time begins when the physician begins to prepare the patient for the induction of anesthesia and ends when the physician is no longer in personal attendance.

If more than one surgical procedure is done during the same sedation episode, the anesthesia code for the most complex procedure is coded and the combined total time for all procedures would be used, says Norris.

CPT^® also instructs to use both the anesthesia code itself and a physical status modifier. These modifiers contain the letter "P' and a number from 1 to 6:

Coding example: For a patient with mild systemic disease receiving deep sedation services for a bronchoscopy, the anesthesia portion would be reported as: 00520-P2.

Qualifying circumstances are add-on codes to represent specific situations where anesthesia services are particularly difficult. They are coded in addition to the primary anesthesia code. For example, qualifying circumstances code 99100 is defined by CPT^® as, "Anesthesia for patient of extreme age, younger than 1 year or older than 70."

There is also a qualifying circumstances code for anesthesia complicated by emergency conditions, +99140 (Anesthesia complicated by emergency conditions [specify] [List separately in addition to code for primary anesthesia procedure]) An emergency condition is defined as one where "a delay in the treatment of the patient would lead to a significant increase in the threat to life or body part", such as a significant crush injury to an extremity or gunshot wound to the head. Providers should document if such an emergency condition exists.

Work Closely With Payers

Norris adds, there are numerous billing related issues that should be addressed and understood before undertaking the coding and billing of anesthesia codes.

For those payers that utilize the CCI edits, which includes Medicare, the ED evaluation and management levels 99281-99285 are bundled into the anesthesia codes, with no modifier allowed to override this edit. Critical Care services (99291-99292) are separately billable.

And facility required credentialing to provide anesthesia services should be addressed with the physician practice; this is something that the physicians will have to discuss with their hospital, advises Norris.

Brush Up on Medicare Anesthesia Rules

Payor contracts may have to be modified for reimbursement to the ED physician for anesthesia services. Individual payer policies on anesthesia services should be researched, says Norris.

Medicare has specific anesthesia billing guidelines that you'll need to apply to accurately code ED anesthesia services.

First of all, there is a separate Anesthesia Conversion Factor ("CF") that is updated annually. At the time of publication, payments for 2012 Medicare fee schedule were still uncertain. For 2011 the National Anesthesia CF is $21.0515. CMS adjudicates anesthesia claims using a geographically adjusted CF. For example in 2011, the Anesthesia CF for North Carolina is $20.31.

Medicare calculates anesthesia payment by using [(Base + Time) x Geographically Adjusted Anesthesia CF]. The base units assigned to each anesthesia procedure can be found on the CMS website and this file is updated annually.

The time units are calculated by Medicare in 15 minute units; the actual Anesthesia time (defined by Medicare as the period that the anesthesia practitioner is present with the patient) should be reported on the claim.

Watch the clock: Anesthesia time starts when the anesthesia practitioner begins to prepare the patient for anesthesia services and ends when the anesthesia practitioner is no longer furnishing anesthesia services, (i.e., when the patient may be placed safely under postoperative care).

Test Your Knowledge: Review this E D Medicare anesthesia coding example from Norris:

The scenario: A 60 year old otherwise healthy patient presents to the ED with a Colles fracture requiring manipulation to reduce the fracture. The patient's pain is severe and the emergency physician makes the treatment decision to provide deep anesthesia to the patient for the reduction. Another EP from the physician group provides the anesthesia while the primary EP reduces the fracture. The EP documents 15 minutes of deep sedation.

First step: Looking in the CPT^® index under the main heading "Anesthesia" and then under the subheading "forearm" (00400, 01810-01820, 01830-01860) or "wrist" (00400, 01810-01860), you will find a range of anesthesia codes to check.

The answer: After reviewing these code ranges, you can see that the best choice is CPT^® 01820 (Anesthesia for all closed procedures on radius, ulna, wrist or hand bones). The AA Medicare Anesthesia modifier P1 physical status modifier should be appended to the anesthesia code.

Utilizing the 2011 Anesthesia Base Unit file on the CMS website, the base units assigned for CPT^® 01820 are 3 base units. The 2011 North Carolina Medicare allowable for this service is calculated as: [(3 Base Units x 1 15 minute time unit) x $20.13] = $60.93.

Editor's note: Please see "Anesthesia Coder" on Codify for additional anesthesia coding resources.