Anesthesia Coding Alert

Its not uncommon for patients to undergo many diagnostic or therapeutic procedures on an outpatient basis rather than as an inpatient. Coding for anesthesia during these types of procedures, such as radiation or an MRI (01922, anesthesia for non-invasive imaging or radiation therapy), is simple and reimbursement is straightforward if the services take place on different days. But some coders find that reimbursement can get much more complicated if a patient has multiple outpatient procedures on the same day. To optimize reimbursements, learn the requirements of your local carriers and use the appropriate modifiers.

If we schedule more than one procedure on a patient in the same day, its basically because of convenience, says Jan Wirtz, an anesthesia coder and owner of Specialty Billing Services Inc., a firm that specializes in anesthesia billing in Wacona, Minn. If the patient is already coming to the office, why not treat other problems or do other procedures during the same visit as long as medications dont pose a problem? That way the patient doesnt need to schedule additional appointments.

As convenient as that may be for the patient, Wirtz points out that its actually in the physicians financial interest to schedule procedures on separate days. Most insurance carriers have reimbursement guidelines that encourage physicians to schedule patients procedures on different days. Insurance companies will only pay half of their usual allowances for the second or third procedures done on the same day. If a doctor wants to get paid the full allowance, the procedures need to be done on different days, she says.

Multiple Billing Successes

Using modifier -59 (distinct procedural service) is the best route around the multiple procedure reimbursement problem, when it is appropriate, says Marilyn Wilson, billing manager with Southeastern Pain Management, an anesthesia practice in Gadsden, Ala. Medicare accepts it, and most other insurance carriers accept it now that its been in CPT for two years. Some carriers are slower than others updating or changing their policies, but we dont run into many problems using it these days. When we do have a multiple procedure reimbursement problem, its usually because we failed to include a modifier with one of the procedures.

When several procedures are being filed, base the claim on the highest unit procedure and use the total time associated with all the procedures to bill for them, Wirtz says. Two common scenarios include:

1. Placing an epidural catheter to help manage post-operative pain on the same day as general anesthesia: Code the surgery with the American Society of Anesthesiologists (ASA) code for the general anesthesia; 36489-59 (placement of central venous catheter; percutaneous; over age 2-distinct procedural service) for the central venous catheter (CVC); and 62319-59 (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; lumbar, sacral [caudal]-distinct procedural service) for the epidural catheter. (Code 62319 replaces 62279 in CPT 2000.) Of course, this coding is with the understanding that the CVC and epidural are placed at different times from the general anesthesia.

2. Treating neck or shoulder pain and cervical disk problems in a pain clinic setting: Code 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) (Code 62310 replaces 62275 in CPT 2000.) for the epidural steroid block and 20550-59 (injection, tendon sheath, ligament, trigger points or ganglion cyst-distinct procedural service) for the trigger point blocks (TPB). Some carriers may require that you also include modifier -51 (multiple procedures) for multiple trigger point blocks. You may need to file the claim with modifier -59 for the first TPB and modifiers -51 and -59 for subsequent blocks. Use modifier -59 if two or more separately identified procedures (such as an epidural and TPB) were done on the same day.

Know How Your Carrier Wants It

Many of the claims Wirtz files are for anesthesia used for pain management. She agrees that problems with reimbursement usually only arise when a claim is filed without modifiers. However, she does point out that certain carriers may want claims filed in a particular way before they will pay.

1. Line-by-line Billing. Weve had problems in the past with billing trigger point blocks (20550) with Medicare or Blue Shield, Wirtz says. We can bill up to four areas that were injected, but they wont pay if we bill it on one line, using modifier -51 and four units or areas as the number of services. We must bill them line by line, with one block on each line. Line one has 20550 only with the charge for one block; lines two, three and four would each be 20550-51 with the charge for each area injected and one unit.

2. Manually Bill. We also have to bill Medicare manually for trigger point blocks on a paper claim and include a copy of the treatment notes, she continues. They deny the procedures as duplicates every time we file electronically. Blue Shield doesnt require treatment notes, but will pay only if the blocks are billed on four separate lines. It takes more time on the front end to do it this way, but it saves time in the long run since we know this is what they require.

Wilson and Wirtz agree that most traditional insurance companies such as Medica and PreferredOne are good about paying for trigger point blocks and other multiple procedures. The carriers do insist that modifier -51 be included with the claims, which Wilson and Wirtz say is appropriate.

The key is to use the modifiers as appropriate, and find out what your local carriers require, says Wilson. A claims adjuster supervisor can help you file it right. Be sure to check with them whenever you have questions, because it helps all of you if the paperwork is filed correctly the first time.