Each year brings CPT coding changes for most medical specialties, and anesthesia is no exception. ICD-10 also brought in many changes for anesthesia. Since the Centers for Medicare & Medicaid Services (CMS) released its final rule for the CY2018 Medicare Physician Fee Schedule, anesthetists and medical coding companies that specialize in anesthesia billing and coding are preparing for 11 CPT coding updates in 2018. These anesthesia specific updates include new, revised and deleted codes.
New and deleted anesthesia codes
The following anesthesia codes will be deleted as they were identified as potentially misvalued:
- 00740 Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum
- 00810 Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum
The deleted codes will be replaced by 5 new codes to more specifically describe anesthesia services furnished in conjunction with and in support of gastrointestinal endoscopic procedures: two codes for upper GI procedures (007X1 and 007X2), two codes for lower GI procedures (008X1 and 008X2), and one code for upper and lower GI procedures (008X3)
- 007X1 Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum; not otherwise specified
- 007X2 Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum; endoscopic retrograde cholangiopancreatography (ERCP)
- 008X1 Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; not otherwise specified
- 008X2 Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; screening colonoscopy
- 008X3 Anesthesia for combined upper and lower gastrointestinal endoscopic procedures, endoscope introduced both proximal to and distal to the duodenum
Handling Common Anesthesia Coding and Billing Challenges
A higher level of coding skills are necessary to report anesthesia services as there are many complexities involved in coding and billing for this specialty. That’s why most providers prefer to outsource the task to a medical billing and coding company with experience in the field. This can help avoid errors that put providers at increased risk for compliance issues and audits. Here are the key elements contributing to the complexity of billing anesthesia services:
- Types of anesthesia: The continuum of complexity in anesthesia services (from least intense to most intense) ranges from:
- Local or topical anesthesia
- Moderate (conscious) sedation
- Regional anesthesia
- General anesthesia
- Minimal sedation
- Reporting anesthesia time: Anesthesia time is a continuous time period from the start of anesthesia to the end of an anesthesia service. A key factor in coding and billing is the calculation of base units and the use of conversion rates for total anesthesia time. Base units are the numeric value that Medicare has attached to the anesthesia CPT codes for anesthesia services. For example, 00560 Anesthesia for procedures on heart, pericardial sac, and great vessels of chest, without pump oxygenator has a weight value of 15 base units. The following formula has to be used to report time units for anesthesia services to commercial payers:
Base Units + Time + Physical Status Modifier = Total Units
For Medicare, the formula is used to report time units for anesthesia provided is:
Base Units + Time = Total Units
In calculating anesthesia time, the anesthesia practitioner can add blocks of time around an interruption in anesthesia time as long as the anesthesia practitioner is furnishing continuous anesthesia care within the time periods around the interruption. The information should be documented so that an auditor can see the continuous and discontinuous periods of anesthesia.
Anesthesiologists need to determine how to properly code for their time spent in surgery and choose the method that best describes the intensity of service provided. They also have to use specific conversion rates for total anesthesia time. Providers have to figure out which of the codes applies to an individual case, which can be really challenging as there are over 13,000 anesthesia codes. Moreover, anesthesiology codes are much more complex than that of other specialties, and providers need to be vigilant to avoid coding errors.
Another consideration is regarding arterial, central line, regional blocks, epidurals, etc. These should be coded as separate procedures. These services are not included in the reported anesthesia time and are billed separately. Pain management services should also be reported in conjunction with an operative anesthesia service.
- CPT code modifier use: There are several modifiers in anesthesia and providers need to know how to use them correctly. They need to report the appropriate modifier to denote whether the service was personally performed, medically directed, or medically supervised. The HCPCS modifiers applicable for billing Medicare are: AA, QY, QK AD QX and QZ. For instance, modifier QK tells the payer to make adjustments for the anesthesiologist medically directing 2, 3 or 4 cases at the same time he or she is directing the CRNA on the reported case. Modifier AD describes a situation similar to that indicated by modifier QK, but with more involvement and more than four concurrent anesthesia procedures.
- Medical necessity: When billing for monitored anesthesia care (MAC), documentation must support diagnosis. Providing evidence of medical necessity is necessary to ensure reimbursement and compliance with a local coverage determination (LCD). LCDs differ from carrier to carrier and change rapidly, and knowledge about LCDs is crucial for accurate reporting.
- Documentation requirements for cancelled cases: Documenting cancelled cases correctly will allow coders to provide the right codes. Procedures cancelled before induction must be reported using the correct evaluation and management code. The reason why the case was cancelled must be given, such as case cancelled due to equipment failure. Procedure cancelled after induction should be reported with the appropriate modifier, -53 (discontinued procedure), -73 (procedures discontinued prior to anesthesia), or -74 (procedures discontinued after anesthesia administration or after the procedure has begun), plus time. If the payer does not accept a modifier, these cases can be billed using the correct anesthesia code with the full base units for the procedure that was scheduled, plus total time that is documented on the anesthesia record. The documentation should clearly specify the reason for the cancellation.
Errors related to CPT codes, surgery time, or who was present during the surgery can undervalue anesthesia services and lead to loss of revenue. The trickle-down effect of undervalued services can impact the healthcare industry as a whole. Coding errors can also result in significant overpayment and increase risk of scrutiny by RAC auditors.
Partnering with a reliable medical billing company can help avoid such issues. In addition to ensuring accurate reporting to prevent claim denials, experienced service providers can also help anesthesiologists take advantage of additional reimbursement opportunities. For instance, if the services are deemed reasonable and necessary, reporting certain qualifying circumstances can mean higher payment for the anesthesiologist or CRNA. As an example, an AAPC report points out that reimbursement for +99100 Anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure) is 1 unit of anesthesia. Leaving out +99100 would lead to loss of reimbursement for the provider. Reporting of qualifying circumstances will also promote better documentation of the patient chart and improved compliance. Appending physical status modifiers for reporting the overall physical health of a patient at the time of a procedure or encounter is another strategy that can have a positive impact on anesthesia reimbursement.