Anesthesia Coding Alert

By Barbara Johnson, CPC, MPC
Consulting Editor

Anesthesia historically has been difficult to code and bill and still is. Issues such as inadequate information, improper use of diagnosis codes, and carriers who deny anesthesia services if the code does not match that of the associated procedure provided by the surgeon create the challenge. This article should help you guide anesthesiologists and CRNAs in providing the type of information you need to code correctly and receive appropriate reimbursement.

Inadequate Information

Very often, the diagnosis leading to the procedure that requires anesthesia is vague and incomplete. Abdominal pain (789.0X), pelvic pain (625.9) or tumor (239.X) might be the only information a coder receives. For example, a physicians notes might indicate elevated BP, but you cant code or bill elevated BP. The coder cannot possibly know whether the patient has hypertension (401.9) or just elevated blood pressure without documented hypertension (796.2). Similarly, many patients take Synthroid or Levoxyl, but their chart does not mention hypothyroidism (244.9). One of the best examples of incomplete information Ive ever seen was a transabdominal hysterectomy (58150) with a diagnosis of motion sickness (994.6).

Many other issues consistently present coding difficulties, including those below.

Pathology information. Because anesthesia professionals rarely have access to it, they should not change any notations of tumors, lesions or masses and simply code the diagnoses for their purposes as neoplasms of unspecified etiology. Even using the uncertain behavior codes with neoplasms is risky, because that implies the possibility of labeling the patient as having a malignant tumor. This makes it a permanent part of the medical record and/or chart, and could lead carriers to deny the patient insurance in the future.

Diabetes mellitus 250.XX is difficult to code. Anesthesia providers commonly use DM as a code abbreviation, but frequently dont provide additional information thats required for correct coding and matching reimbursement, such as Type I (insulin dependent) or Type II (non-insulin dependent), controlled or uncontrolled. Diabetes complications, such as neuropathy, nephropathy and retinopathy all common problems that require a different approach to coding frequently suffer from the insufficient chart information syndrome.

See chart. Many physicians believe see chart is adequate information for the coding staff. The problem is that the majority of coders dont see the chart. Information about medications or something as simple as a hemoglobin count should always be included in the anesthesia record for coding purposes. The hemoglobin count can provide the kind of information that allows staff to code a condition more accurately and possibly provide an additional diagnosis for anemic patients. For instance, it can help clarify whether the anemia is due to blood loss (code 285.1 for acute, or 285.0 for chronic), is aplastic (284.9) with the [...]