EM Coding Alert

Question: Are there any guidelines as to when an anesthesiologist can bill separately for an evaluation and management (E/M) level of service and what the documentation must include? The services must go beyond the provision of routine preoperative services, right?

Alabama Subscriber

Answer: According to an article by the American Society of Anesthesiologists (ASA), “Under specific conditions, E&M services can be billed using the appropriate E&M code that reflects the level of service provided to the patient; however, to bill for E&M services requires that specific criteria are met and that the services can be clearly differentiated from those included as part of the anesthesia services.”

“When providing a service unrelated to routine anesthesia care, the key issues from a coding and billing perspective are that there be (1) specific and detailed documentation of the request, (2) clarification that the service is not included in routine perioperative anesthesia care which is covered by the anesthesia charge and (3) appropriate documentation of the extent of the clinical evaluation and clinical decision-making to support the claim and billing code,” the April 2015 ASA article notes.

Note: Make sure to check the current E/M codes and guidelines, as there have been several code changes since the publication of this article.

Resource: Find the article at www.asahq.org/-/media/sites/ asahq/files/public/resources/practice-management/ttppm/2015- 04-13-reporting-em-or-tcm-codes.pdf.