Anesthesia Coding Alert

Swan-Ganz, A-lines, IVs, central venous catheter placements (CVP) these are all types of lines that anesthesia providers place for patients on a regular basis. The procedures are common, but billing and reimbursement for the services can be a gray area because some lines are bundled while others are not, and some may be bundled depending on the situation. By ensuring that adequate documentation is in place, anesthesia practices will have an easier time receiving reimbursement in the appropriate situations.


Whats Bundled, Whats Not


Some providers believe that coding for line placement is cut and dry: CVPs, Swan-Ganz catheters and arterial lines are not bundled with the procedure; IVs and related lines are. But it is not necessarily that simple for other providers because part of determining which codes to use may lie in when the line was placed and who placed it, not just which type of line was used.

If the patient is a nonsurgical patient in the ICU [intensive care unit] or is in the OR [operating room] suite or holding area when the line is placed, the placement is separate from the basic anesthesia care performed as part of the anesthesia for the patients surgery or medical care, says Jan Wirtz, owner of the anesthesia billing firm Specialty Billing Services Inc. in Waconia, Minn. Medicare determined at one point that these placements were bundled with the anesthesia service. The American Society of Anesthesiologists (ASA) fought it several years ago, and Medicare then reversed its decision so that separate billing is allowed now.

Wirtz adds that the anesthesiologist must place the line personally rather than simply be present at the placement before it can be billed. Its a flat rate fee that the anesthesiologist charges, but no anesthesia time for the service is applicable. At least thats the guideline passed down from the Minnesota Medicare carrier.

Robin Fuqua,CPIC, a certified insurance coder with the medical group Anesthesia Consultants of California in Escondido, agrees. Our rule of thumb is that we bill separately for any line that is placed by our anesthesiologists separate from the main surgical procedure, provided we do not violate any Medicare or Medicaid rules or the terms of agreement we have with various HMOs and group insururers.


Choose the Right Code


Anesthesiologists place lines for a variety of nourishment, medication or monitoring needs. Once the need is determined, the physician follows documentation guidelines, and the line placement legitimately qualifies for separate billing. There are several codes to choose from for billing purposes. Here are some examples:


36489* (placement of central venous catheter [subclavian, jugular or other vein] [e.g., for central venous pressure, hyperalimentation, hemodialysis or chemotherapy]; percutaneous, over age 2) could be used for a patient having pulmonary surgery to monitor his or her right heart filling pressures and to provide central access to vasoactive drugs during surgery.

36620 (arterial catheterization or cannulation for sampling, monitoring or transfusion [separate procedure]; percutaneous) could be used to monitor a patients blood pressure on a moment-to-moment basis during open-heart surgery.

36830 (creation of arteriovenous fistula by other than direct arteriovenous anastomosis [separate procedure]; non autogenous graft), known as an AV or Gortex graft, is used for blood dialysis on patients with kidney failure.

36533 (insertion of implantable venous access device, with or without subcutaneous reservoir) is used to report various catheters (such as double lumen, triple lumen, Hickman or port-a-cath) used for infusion of chemotherapy in cancer patients. Patients who are in a coma or are unable to eat also may have lines placed so that they can be intravenously fed.

Modifier -59 (distinct procedural service) may help practitioners receive reimbursement in some areas. It might be helpful to use modifier -59 for those who might be having difficulty with carriers that deny these procedures as bundled, advises Tonia Raley, CPC, a claims processing team leader with the Phoenix consulting firm, Medical Information Management Solutions. However, make sure that you have your documentation to support it.

Codes 36530 (insertion of implantable intravenous infusion pump) for Groshong catheters, 49420* (insertion of intraperitoneal cannula or catheter for drainage or dialysis; temporary) for CAPD or Cruz catheters, 49421 (insertion of intraperitoneal cannula or catheter for drainage or dialysis; permanent) for Tenckhoff or permacath, and 93503 (insertion and placement of flow directed catheter [e.g., Swan-Ganz] for monitoring purposes) for Swan-Ganz catheters also may be used in certain situations. The kinds of lines placed and the number placed are determined by how sick the patient is, what kind of operation is being performed and what information is needed to monitor the patient adequately, Fuqua says. It is important to know exactly what the line was placed for so it can be billed with the proper code.

The multiple surgery rules do not apply to these codes, according to the Medicare fee schedule, Raley adds. You cannot bill these codes using modifier -51 (multiple procedures).


Document Completely


Thorough documentation of line placements is the key to getting reimbursed for them. To bill separately for the placement and monitoring of these lines, the anesthesiologist must clearly document on the anesthesia record that he or she personally placed the line(s), says Raley. You cant bill separately for the line(s) if the anesthesiologist only did the monitoring and didnt place the line.

Medical necessity for the line also must be stated in the patients record. If those types of things arent documented or performed, many coders say the placement is not billable.

Fuqua says it is important to be familiar with what the local carrier requires for reimbursement. Medi-Cal (Californias Medicaid carrier) has very strict rules about catheter charges, she explains. They will only pay for one main service per day; all other services are considered bundled with the main service. If the only service performed on the patient that day is the placement of a couple of catheters, they will still pay for only one. The only exception to this is if different physicians in the medical group place the separate lines at different times of the day.

Even with adequate documentation, some carriers will only pay for a certain number of catheters, no matter how many are necessary for the patients situation. For example, Fuqua says Medicare will pay for two catheters during a procedure (such as coronary artery bypass graft [CABG] surgery), but will not pay for three. They consider the CVP and the Swan-Ganz to be relatively the same, and will only pay the lower priced of the two. Billing for multiple lines, however, may be accepted in other areas or in certain situations.

You can bill separately for placement of CVP and Swan-Ganz lines as long as it is clearly documented that they are two separate lines, and the medical reason for the two separate lines also is documented on the anesthesia record, Raley says. But you cannot bill for a CVP and Swan-Ganz if the CVP port is used to thread the Swan-Ganz catheter you can only bill for the Swan-Ganz.

Some HMO or group insurance carriers will bundle some or all catheter placements with a major procedure such as CABG surgery or other heart procedures. Fuquas group agrees to write off the charges if the catheter is placed during the anesthesiologists time in surgery. If the catheter is placed later, the group presses for payment because the service was performed separately from the main procedure. She adds that having a copy of the physicians progress notes showing the date and time of placement after the surgery as well as his or her post-surgical observations of the patient help improve the chances of receiving reimbursement in these situations.

The physicians in Fuquas group use forms that make it easy to correctly document the placement of lines. Every anesthesia record has an area where various lines and auxiliary services are listed. All the anesthesiologist must do is circle the name of anything he or she did to show that it was done. There is also space to list all medications and dosages, as well as a blank area where the anesthesiologist can write a running log of tasks performed and in what order throughout the surgery or procedure.


Regulatory Clarification


We have just gone round and round with our compliance people on when the placement of a line is billable, says Leisa Gonnella, director of administration for the University of Virginias anesthesiology department. Obviously, there has been no real clarification of this from the regulatory bodies. The University of Virginia currently works under the guideline that a line is billable like a surgical procedure if all the documentation backs it up.

Wirtz agrees that there is some confusion about which lines are covered and which are not. I reviewed two other publications I receive and got two different answers, she says. One stated that CVP lines and A-lines are both covered, and the other stated that CVP lines are covered but A-lines are not. I know we send them both to Medicare and other carriers and have not had a problem with payment for several years. If the line placement is billed on the same day as surgery, we add modifier -59 (distinct procedural service), but those are the only cases weve encountered problems with sometimes.


Check With Local Carriers


Wirtz and Fuqua agree that the final word on whether line placements are separately billable should come from local authorities. Minnesota has allowed them to be billed separately, but coders should check with their local carriers, Wirtz says. Always get clarification from your local Medicare carrier or your local medical society if you have any doubt about billing for a line.

I highly recommend that billers check with their local Medicare and Medicaid providers to make sure they comply with all billing requirements, since these can vary from state to state and even from provider to provider, says Fuqua. Read all of your HMO and group insurance contracts so youre familiar with what they want. And make sure all line placements are documented on the anesthesia record before billing for payment on them.

Another way to ensure that your carriers will pay for lines separately is making sure that lines are a part of your contract negotiations, Raley adds. Having it clearly stated in the contract that lines will be paid separately should help the situation.