Internal Medicine Coding Alert

Question: We removed six papillomas from a patient, and we administered three different Xylocaine injections to numb the various areas. Can I bill for these injections? I was planning to bill 90782-47 (Therapeutic, prophylactic or diagnostic injection; subcutaneous or intramuscular; anesthesia by surgeon). Is this correct?

Iowa Subscriber

Answer: No. Local anesthesia is always included in the surgical procedure. The CPT definition of surgical package is in the surgery guidelines section and states, "the following services are always included in addition to the operation per se: local infiltration, metacarpal/ metatarsal/digital or topical anesthesia." Local infiltration refers to the injection of Xylocaine or other types of local anesthetics into the tissues. In addition, modifier -47, by definition, also excludes local anesthesia. It is only applicable to regional or general anesthesia. Even then, Medicare and many other payers do not reimburse for regional or general anesthesia administered by the surgeon, in part because of safety and quality-of-care concerns for the patient.

There is one type of anesthesia that the physician performing the procedure can sometimes be paid for 99141 (Sedation with or without analgesia [conscious sedation]; intravenous, intramuscular or inhalation) and 99142 (... oral, rectal and/or intranasal). CPT defines conscious sedation as "sedation used to achieve a medically controlled state of depressed consciousness while maintaining the patient's airway." The physician performing the procedure prescribes the sedation, and a "trained observer," usually the office nurse or medical assistant, monitors the patient during and after the procedure.

In the internist's office, it can be used for procedures that are painful or anxiety-provoking such as reductions of dislocations or fractures, endoscopies, or lumbar punctures. Although Medicare has assigned RVUs to these codes, it considers conscious sedation to be bundled into the procedure performed. However, some commercial payers and state Medicare agencies will reimburse. Check with your local carrier.