Anesthesia Coding Alert

Hint: Reporting provider relief involves capturing time units accurately.

Coding anesthesia for complex cardiac and neurosurgical procedures is not so different than coding and billing for simpler cases, but they do present distinct coding and billing challenges. Lengthy procedure times, invasive monitoring techniques, and documentation requirements all pose a challenge when billing for these complex procedures.

As always, report the anesthesia service using codes in the 00100 (Anesthesia for procedures on salivary glands, including biopsy) through 01999 (Unlisted anesthesia procedure(s)) range. With only one anesthesia code reported it is important to not only capture the accurate code for highest base unit value reimbursement, but also the add-on codes, such as arterial lines, central venous lines, and pulmonary artery catheters that you may be able to report.

Understand What Distinguishes Certain Procedures as Complex

Due to the lengthy procedure times of certain complex cardiac and neurosurgical operations, multiple anesthesia providers may be involved. It is important that all handoffs of anesthesia care are documented clearly in the record so you can accurately capture time units. It is best practice for a provider type to relieve the same provider type. So, certified registered nurse anesthetist (CRNA) relieves CRNA, and physician relieves physician.

Some examples of complex cardiac and neurosurgical procedures may include the following:

• CABG (coronary artery bypass grafting)
• Valve repairs or replacements
• Aortic surgery
• Craniotomies
• Cerebral aneurysm procedures
• Spinal cord surgery
• Intracranial tumors or vascular procedures
• Complex cervical and thoracic spine procedures

The American Society of Anesthesiologists (ASA) Relative Value Guide^® states that placement of arterial, central venous, or pulmonary artery catheters, and use of transesophageal echocardiography (TEE), are not included in the base unit value. These are commonly used during more complex procedures and you can bill them in addition to the base and time unit values. When determining if you can bill these codes, ask a few questions:

• Who performed the service?
• Is it separately reportable?
• Is there sufficient documentation to support the service?

When the anesthesia team is involved in the TEE, it is important that documentation includes what specific components of the TEE the team is involved in. There are several choices for code selection. The anesthesia team may be involved in all components of the TEE, such as probe placement, image acquisition, and interpretation and report; or only part of the TEE, such as probe placement. You should only bill for components the anesthesia team is responsible for, and clear documentation is a necessity.

Check Your Payer’s Policies When Reporting These Additional Complications

You may also capture additional reimbursement via the patient’s physical status and any applicable qualifying circumstances. Some payers, such as Medicare, may not provide any additional reimbursement for these, so it is important to know your payer policies.

The physical status classification is used to communicate the patient’s comorbidities. The patient’s physical status is captured by the following modifiers and should be appended to the claim, if applicable, based on payer:

• P1 (Normal, healthy patient): No additional base unit value
• P2 (Mild systemic disease): No additional base unit value
• P3 (Severe systemic disease): 1 additional base unit value
• P4 (Severe systemic disease that is a constant threat to life): 2 additional base unit value
• P5 (Moribund, not expected to survive without the operation): 3 additional base unit value
• P6 (Declared brain-dead patient whose organs are being removed for donor purposes): No additional base unit value

You may add qualifying circumstance codes to the claim if applicable and based on payer policies. When using these codes take note of the RVG comments, as there are restrictions on what codes these can be reported in conjunction with:

• +99100 (Anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure))
• +99140 (Anesthesia complicated by emergency conditions (specify) (List separately in addition to code for primary anesthesia procedure))
• +99116 (Anesthesia complicated by utilization of total body hypothermia (List separately in addition to code for primary anesthesia procedure))
• +99135 (Anesthesia complicated by utilization of controlled hypotension (List separately in addition to code for primary anesthesia procedure))

Try Your Hand at These Examples

Example 1: A 78-year-old patient undergoes an open mitral valve replacement under general anesthesia. The anesthesia team places the TEE probe and an arterial line. This patient is classified as a physical status 4 based on comorbidities.

You can bill the following codes for this service:

1. 00562 (Anesthesia for procedures on heart, pericardial sac, and great vessels of chest; with pump oxygenator, age 1 year or older, for all noncoronary bypass procedures (eg, valve procedures) or for re-operation for coronary bypass more than 1 month after original operation)-P4, which reports the anesthesia code billed for mitral valve replacement plus physical status modifier
2. 36620 (Arterial catheterization or cannulation for sampling, monitoring or transfusion (separate procedure); percutaneous) to capture arterial line placement
3. 93313 (Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode recording); placement of transesophageal probe only) to capture placement of TEE probe
4. 99100 to reflect the patient being older than 70

You should review payer policies to determine if the physical status modifier and qualifying circumstance code 99100 should be billed or if additional reimbursement will be received for these circumstances.

Example 2: A 54-year-old patient undergoes a craniotomy for brain tumor resection. The anesthesia team places an arterial and central venous line. This patient is classified as a physical status 3 based on comorbidities.

You can bill the following codes for this service:

1. 00210 (Anesthesia for intracranial procedures; not otherwise specified)-P3 to report anesthesia for craniotomy plus physical status modifier
2. 36620 for the arterial line placement
3. 36556 (Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older) for the central venous line placement

The above examples are simplified real-world examples and only include anesthesia and CPT^® coding. Other things to consider to fully capture the case are anesthesia times, any applicable handoffs between providers, and any medical direction modifiers applicable based on documentation.

Coding for complex cardiac and neurosurgical procedures requires careful attention to not only accurate anesthesia code selection, but also any additional reimbursement opportunities that may be available, such as placement of arterial and central venous lines, physical status, and qualifying circumstance reporting. Each of these services must be supported by the documentation, and knowledge of payer rules is crucial. By reviewing all of these elements, you can capture these complex procedures for maximum accurate reimbursement.

Julie McDaniel, MHA, CPC, CANPC, Contributing Writer