Anesthesia Coding Alert

Coding for anesthesia during spinal surgery can be almost as complex as the surgeries themselves but having thorough documentation of the case and knowing the ins and outs of specific codes can help you master the challenges. Instrumentation Challenges "I think the main challenge with coding for spinal column or spinal cord surgery is getting the anesthesiologist to document instrumentation," says Carla Thibodeaux, CPC, anesthesia coder with the physician group Tejas Anesthesia in San Antonio. "Cages, Harrington rods, and anterior or posterior instrumentation may be used for these procedures, and it makes a big difference in reporting the procedure accurately."

Instrumentation is usually placed in the spinal column when stability is important. It can be done on all or part of the spine but tends to be necessary over multiple levels.

Reporting the instrumentation is needed to keep claims accurate, but is also makes a big difference in the physician's bottom line since it adds several units to the procedure's base units. Most codes for anesthesia during spinal procedures have 8-10 base units, but the code for instrumentation during these procedures is a 13-unit code.

For example, instrumentation is sometimes used for spinal procedures such as PLIF (posterior lumbar interbody fusion). Anesthesia for the PLIF procedure has a base value of 8 (code 00630, Anesthesia for procedures in lumbar region; not otherwise specified), but using instrumentation means it qualifies for code CPT 00670 instead (Anesthesia for extensive spine and spinal cord procedures [e.g., spinal instrumentation or vascular procedures]). If the instrumentation is clearly documented in the patient's record, the anesthesiologist can code with 00670 and charge a total of 13 base units (plus time units) for what normally would have been an 8-unit procedure (plus time). The same substitution applies to procedures such as cervical fusion, when 13 units for code 00670 can be reported instead of 10 units for 00600 (Anesthesia for procedures on cervical spine and cord; not otherwise specified).

"We're trying to communicate with our physicians about this issue, but they often don't mention the instrumentation even though it carries extra units," says Cindy Clark, anesthesia coding supervisor with Anesthesiology Consultants in Savannah, Ga. "Most of the time I learn that instrumentation was used by reading the operative notes."

So if administering anesthesia during procedures with instrumentation makes such a difference in reimbursement, why do physicians often fail to mention it? ACA experts cite these possibilities:

Many physicians don't know that instrumentation carries more start-up fees than the standard procedure. There is usually no difference in anesthesia fees for similar situations a hernia procedure with mesh and one without mesh are paid the same. Because of this, many anesthesiologists don't know that instrumentation in the back makes a difference to [...]