Anesthesia Coding Alert

Many patients who undergo serious surgical procedures like total knee replacement (27447, arthroplasty, knee, condyle and plateau; medial and lateral compartments with or without patella resurfacing) or shoulder resection (23077, radical resection of tumor [e.g., malignant neoplasm], soft tissue of shoulder area) often require additional pain management medication for several days following the process. Others need relief from chronic pain. Whether this is in the form of epidural or subarachnoid injections or a femoral or interscalene block, reimbursement is possible, in addition to the original procedures anesthesia. By working with local carriers and ensuring that documentation supports the diagnosis codes considered medically necessary for the service, anesthesia providers can reap the rewards of providing continuous pain management care.

Clearly Document Separate Purposes

One of the most important facts to document in the patients record is that the post-op anesthesia is completely separate from the procedural anesthesia. Epidural and subarachnoid injections usually are coded using 62310 (injection, single [not via indwelling catheter], not including neurolytic substances, with or without contrast [for either localization or epidurography], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or subarachnoid; cervical or thoracic) or 62311 (injection, single [not via indwelling catheter], not including neurolytic substances, with or without contrast [for either localization or epidurography], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or subarachnoid; lumbar, sacral [caudal]).

Injections including catheter placement usually are coded using 62318 (injection, including catheter placement, continuous infusion or intermittent bolus, not including neurolytic substances, with or without contrast [for either localization or epidurography], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or subarachnoid; cervical or thoracic) or 62319 (injection, including catheter placement, continuous infusion or intermittent bolus, not including neurolytic substances, with or without contrast [for either localization or epidurography], of diagnostic or therapeutic substance[s] [including anesthetic, anti-spasmodic, opioid, steroid, other solution], epidural or subarachnoid; lumbar, sacral [caudal]).

Depending on the situation and the documentation in the patients chart, these codes may not be eligible for use as separate pain management codes following a procedure. Consider these examples:

A catheter may be the mode of anesthesia for the surgery and then used postoperatively for pain management. In this situation, you should bill the applicable anesthesia code for the procedure like 27447 (total knee replacement) on the day of surgery and bill 01996 (daily management of epidural or subarachnoid drug administration) for the following days.

The surgeon and/or anesthesiologist may decide up front that the patients postoperative pain will be significant enough to require a higher level of pain management. If so, a catheter may be placed preoperatively with the intent of using it only for postoperative pain management. In this case, it is appropriate to bill the applicable anesthesia code as well as the appropriate injection code (62318 or 62319) for placing the epidural or subarachnoid catheter. You also should append modifier -59 (distinct procedural service) to indicate that the epidural is a separate and distinct service from the original anesthesia, according to Devona Slater, CCMP, president of Auditing for Compliance and Education, a Leawood, Kan.,consulting firm that focuses on physician compliance plans in anesthesia and pain management. Each following day that includes an injection through the catheter for pain management would be coded as 01996.

Once the patient is awake and alert after the procedure, the surgeon and/or anesthesiologist may determine that the patients pain is sufficient to justify a higher degree of pain control. This situation would be coded with the applicable anesthesia code like, 00600 (anesthesia for procedures on cervical spine and cord; not otherwise specified) for anesthesia during back surgery, and the appropriate code for the placement and injection of an epidural or subarachnoid anesthetic (such as 62318). Again, any additional days using the catheter for injection of pain management medication would be coded with 01996.

Follow Local Guidelines

All Medicare carriers have local medical review policies (LMRPs) that address situations such as acute pain management control. Shena Scott, MBA, CMPE, administrator of Brevard Anesthesia Services, a physician group in Melbourne, Fla., says it is important to keep up-to-date with the policies your state now enforces. We just had new LMRP guidelines for billing pain management epidurals for chronic pain go into effect this spring. It can be hard to keep up with all the local changes, but
its imperative if you want to get reimbursed for
your services.

For example, the Florida Medicare policy outlines a number of ICD-9 codes that support medical necessity for postoperative pain control. These include conditions like reflex sympathetic dystrophy of the upper or lower limb (337.21-337.22, respectively); intervertebral disc disorders (722.0-722.93); cervicalgia (723.1); and pathologic fracture of vertebrae (733.13). The policy clearly states that any diagnosis codes not listed in this section will not be covered. The policy also lists V58.49 (other specified aftercare following surgery) as the correct code to bill for acute postoperative pain management.

Slater cites carriers in other states such as Blue Cross/Blue Shield of Kansas, Cigna of North Carolina and Ten State United in Colorado as others that have specific LMRPs related to epidurals and pain management. Coders should be up-to-date on the local policies for the state in which they are coding. One helpful resource for many coders is the Web site www.lmrp.net, a site sponsored by the Health Care Financing Administration (HCFA) that lists local policies from across the country. Users should be aware that the site is updated quarterly, so the latest versions of policies may not be online. Local contractors should have the latest, most up-to-date versions on their individual Web sites. If you do not have access to the Web, call your local carrier for information.

Some anesthesia providers can be reimbursed for acute pain management services by billing the appropriate procedure code like 64450 (injection, anesthetic agent; other peripheral nerve or branch) and modifier -59. It is still important to file the claim with a diagnosis code that the carrier accepts when billing for postoperative
pain control.

Coders may be able to use the site of pain as the primary diagnosis with V58.49 as the secondary diagnosis. For example, 786.52 (painful respiration), 789.0 (abdominal pain) or 724.2 (low back pain) could all be coded as the primary diagnosis, with V58.49 as the secondary diagnosis.

Whatever codes you determine are most appropriate, coding professionals agree that written documentation stating that the surgeon requests the anesthesiologists services to manage post-op pain is necessary. Most insurance carriers consider post-op pain management to be the surgeons responsibility and incidental to the surgery unless he or she specifically requests assistance from the anesthesiologist. Work with your local carrier and document everything in the patients record to support
the billing.