Anesthesia Coding Alert

Laryngoscopies and bronchoscopies are performed fairly frequently, especially to diagnose respiratory ailments or clear newborns' airways. In some of these cases, an anesthesiologist might have to perform an intubation as a separate procedure or provide general anesthesia in conjunction with the laryngoscopy or bronchoscopy. However, under CPT anesthesia guidelines, laryngoscopy (31505-31579) and bronchoscopy (31622-31656) are bundled codes, which usually do not include administration of general anesthesia nor permit billing intubation as a separate procedure. The coder's challenge is to know when to bill intubation as a separate charge, when general anesthesia services are covered for these two procedures, and which codes, modifiers and documentation to append.   Billing Intubation as a Stand-alone Procedure   Securing an airway, or intubation, integral to routine anesthesia administration, is considered a part of the global anesthesia procedure and, therefore, not separately billable. However, if an anesthesiologist intubates a patient for laryngoscopy or bronchoscopy and provides no additional services, virtually all carriers allow billing the procedure separately. For example, if an anesthesiologist performs fiberoptic intubation for a direct laryngoscopy, and it is not part of the anesthetic, it should be covered if you submit it with surgical code 31575 (laryngoscopy, flexible fiberoptic; diagnostic) and appropriate documentation, such as an operative note. 
Cecelia McWhorter, CPC, anesthesia coder with Comp One Services Ltd. in Oklahoma City, suggests using code 31599 (unlisted procedure, larynx) appended with modifier -22 (unusual procedural services) for certain situations. Some commercial carriers pay for fiberoptic intubation for laryngoscopy and bronchoscopy by anesthesiologists in cases that require special skill, perhaps on patients with a difficult history of the procedure or who are morbidly obese," she says. 
Intubations performed in surgical and postsurgical emergencies, even though they might not be associated with a laryngoscopy or bronchoscopy, are usually covered. According to Medicare guidelines, if intubation takes place in the operating suite as part of standard monitoring, the procedure is not separately billable because general anesthesia services include the preparation and monitoring. However, intubation for a rapidly deteriorating patient who will require mechanical ventilation can be billed separately with CPT 31500 (intubation, endotracheal, emergency procedure). Documentation accompanying the claim must include medical necessity, the patient's history and physical status, progress notes and operative record. If the emergency intubation is noted as "stat" or "emergent," use 518.82 (acute respiratory distress/insufficiency) or 518.81 (acute respiratory failure) as the diagnosis, depending on the main symptoms the anesthesiologist documents in the patient's chart. 
McWhorter says an anesthesiologist could be summoned to reintbate a post-op patient who suddenly stops breathing. "Appropriate coding for this case is 31500 appended with modifier -59 (distinct procedural service) if the same pain management specialist who provided anesthesia services during [...]