Updates for Anesthesia Coding and Reporting Guidelines in 2019

Updates for Anesthesia Coding and Reporting Guidelines in 2019

Anesthesia coding and billing can be complex and errors can lead anesthesia groups to become a target of the government’s fraud and abuse detection efforts. In fact, many providers have come to realize the importance of partnering with an experienced anesthesiology medical coding company to report their services correctly. Several anesthesia coding updates and changes to reporting guidelines came into effect on January 1, 2019 and outsourcing medical billing and coding is the best way current with these trends.

In 2019, there are no changes to the CPT codes to report anesthesia care. However, anesthesia guidelines have been updated and now include information on unlisted services/procedures. Here are the key changes that anesthesiologists need to take note of:

  • Guidelines updated to clarify unlisted procedures: In 2019, CPT’s anesthesia guidelines include information on unlisted services/procedures. The goal is to make the guidelines “more consistent with the guidelines for other sections of CPT relative to this matter” (American Society of Anesthesiologists).
  • Changes to neurostimulator coding: There are changes to the CPT codes and instructions associated with the analysis and programming of neurostimulators.
    • 2 codes deleted: Codes 64508 – Injection, anesthetic agent; carotid sinus (separate procedure) and 64450 – Application of surface (transcutaneous) neurostimulator, have been deleted. (Parenthetical notes instruct reporting 97014 for supervision of transcutaneous electrical nerve stimulation (TENS) or 97032 for constant attendance for TENS).
    • Revision of reporting guidelines for codes 95970, 95971 and 95972: There are specific instructions on code 95970 which is used to report analysis for implanted brain, cranial nerve, spinal cord, peripheral nerve, or sacral nerve neurostimulator pulse generator/transmitter.Codes 95971 or 95972 are used to report programming which involves adjusting the system parameter(s) to address clinical signs and symptoms. The 2019 guidelines clarify that parameters may need to be adjusted multiple times during a single programming session. The codes are reported based on the number of parameters adjusted during a session. Simple programming involves adjustment of 1 to 3 parameters and complex programming refers to adjustment of more than 3 parameters. If a single parameter is adjusted multiple times during a session, this is considered one parameter.Analysis is considered inherent to implementation and should not be reported separately if done during the same session.
    • New code descriptors for analysis and programming of spinal or peripheral nerves:
      95970: Electronic analysis of implanted neurostimulator pulse generator/transmitter (e.g., contact group[s], interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with brain, cranial nerve, spinal cord, peripheral nerve, or sacral nerve, neurostimulator pulse generator/transmitter, without programming.
      95971: Electronic analysis of implanted neurostimulator pulse generator/transmitter (e.g., contact group[s], interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with simple spinal cord or peripheral nerve (e.g., sacral nerve) neurostimulator pulse generator/transmitter programming by physician or other qualified health care professional.
      95972: Electronic analysis of implanted neurostimulator pulse generator/transmitter (e.g., contact group[s], interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with complex spinal cord or peripheral nerve (e.g., sacral nerve) neurostimulator pulse generator/transmitter programming by physician or other qualified health care professional.
  • New instructions for imaging guidance: Imaging is included in many of the pain procedures that anesthesiologists perform such as interlaminar epidurals (codes 62321, 62323, 62325, 62327), paravertebral blocks (codes 64461 – 64463), transforaminal epidurals (codes 64479-64484),) TAP blocks (codes 64486-64489), paravertebral facet joint injections (codes 64490-64495) and facet joint ablation (codes 64633-64636). Certain codes that pertain to pumps and neurostimulators also include imaging guidance.Since the above-mentioned pain procedures are included in the surgery section of CPT, the following new CPT instruction in the Surgery Guidelines will apply to them: “When imaging guidance or imaging supervision and interpretation is included in a surgical procedure, guidelines for image documentation and report, included in the guidelines for Radiology (Including Nuclear Medicine and Diagnostic Ultrasound), will apply.”

A proper understanding of CPT codes and ICD-10 codes and use of modifiers is essential for accurate anesthesiology medical billing. In 2019, the coding updates and guidelines for cranial and brain neurostimulator services make this task even more challenging. Partnering with an experienced medical billing and coding company can help anesthesiologists avoid auditor scrutiny and report their services correctly for optimal reimbursement.

What are the Changes, New Codes and Implications of the 2018 PFS for Anesthesia Providers

What are the Changes, New Codes and Implications of the 2018 PFS for Anesthesia Providers

In November 2017, the Centers for Medicare & Medicaid Services released two final rules that would affect payment for physician services. The Medicare Physician Fee Schedule (PFS) Final Rule was published on November 2 and our medical billing company had reported its impact on orthopedic ASCs and therapy-related services. CMS also released the final Quality Payment Program (QPP) rule under which providers participating in MACRA are paid based on the quality of care they provide through either the Merit-based Incentive Payment System (MIPS) or Advanced Alternative Payment Models (APMs). Let’s look at the implications of the 2018 payment update for anesthesia providers as discussed in an Anesthesia News article.Anesthesia Providers

The major changes for anesthesia are as follows:

  • Addition of five codes for anesthesia for gastro-endoscopic procedures and deletion of three low-volume codes
  • Reimbursement for implantation of neurostimulators and the conversion factor has increased
  • Payments for colonoscopies and line placement has been reduced

Here are the details:

  • Five new codes: The anesthesia endoscopy codes were identified as misvalued and a new set of CPT codes have been created to report anesthesia for endoscopies. Anesthesia practices that report codes 00740 (Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum) or 00810 (Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum) will use more detailed codes in 2018:
    • 5 units – 00731 (Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum; not otherwise specified)
    • 6 units – 00732 (endoscopic retrograde cholangiopancreatography [ERCP])
    • 4 units – 00811 (Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; not otherwise specified)
    • 3 units – 00812 (screening colonoscopy)
    • 5 units – 00813 (Anesthesia for combined upper and lower gastrointestinal endoscopic procedures, endoscope introduced both proximal to and distal to the duodenum)

    ERCP now has 6 base units versus 5 previously. On the other hand, reimbursement for screening colonoscopies has been reduced to 3 base units (compared to 5 previously), while other colonoscopies will have 4 base units.

  • Three codes deleted: Anesthesia service codes for extrapelvic (01180) and intrapelvic (01190) obdurator neurectomy and shoulder cast application, removal or repair; shoulder spica (01682) will be deleted due to the low volume of these procedures.
  • Increase in National Anesthesia Conversion Factor: Starting January 1, 2018, the national anesthesia conversion factor increased to $22.1887 (an increase of $0.1443 from $22.0454 in 2017).
  • Changes for line placement: New work values have been assigned for CPT codes for line placement which were identified as potentially misvalued. CPT code 36556 was identified as part of a screen involving high expenditure services with Medicare allowed charges of $10 million or more that had not been recently reviewed. The Insertion of Catheter set was expanded to include CPT codes 36555, 36620, and 93503.
    • 1.93 RVUs – 36555 insertion of non-tunneled centrally inserted central venous catheter; younger than 5 years of age
    • 1.75 RVUs – 36556 Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older
    • 1.00 RVUs – 36620 Arterial catheterization or cannulation for sampling, monitoring or transfusion (separate procedure); percutaneous
    • 2 RVUs – 93503 Insertion and placement of flow directed catheter (eg, Swan-Ganz) for monitoring purposes

    The value lines in the RVG of the American Society of Anesthetists are now listed as “I.C.,” for internal consideration, implying that groups will need to negotiate a rate of reimbursement with commercial carriers.

  • Percutaneous Implantation Of Neurostimulator Arrays: The work valuation for percutaneous implantation of neurostimulator arrays has increased in 2018. CPT codes 64453 (percutaneous implantation of neurostimulator electrode array; cranial nerve) and 64555 (percutaneous implantation of neurostimulator electrode array; peripheral nerve) have been revalued upward around 25%.
  • Changes to Value-Based Modifier: The Value Modifier (VM) applies to payments under the Medicare Physician Fee Schedule (PFS) for physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists who are solo practitioners and physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists in groups with 2 or more eligible professionals (EPs) based on performance in CY 2016. CY 2018 will be based on 2016 performance and is the final year of the VM. The changes to VM are as follows:
    • An upward or downward adjustment will be made to providers’ reimbursement based on how well they performed in 2016
    • Providers participating in MIPS need to report only 6 quality measures in 2016, versus the original requirement of 9
    • The requirement for a cross-cutting measure has been waived
    • Physicians who successfully submit data will avoid a downward adjustment under the VM
    • Penalties for groups that did not participate in the PQRS have been reduced from 4% to 2% (for a group of nine or less, the penalty has been reduced from 2% to 1%).
  • Payment Update for Anesthesia ProvidersIncrease in data completeness threshold: While previously, physicians had to submit quality data on 50% of eligible patients for a particular measure, the 2018 PFS has raised this proportion to 60%. Moreover, in 2018, clinicians need to submit multiple measures and should participate in the improvement activities category to avoid a penalty. The final scoring threshold has been set at 15 points, and providers must score at or above this thresh bold to avoid a penalty.
  • Cost: Practices that are attributed patients will be held accountable for costs. Most anesthesia providers will not be attributed patients, but those that are should know that CMS will be looking at two cost measures – total costs per capita and Medicare spending per beneficiary. Anesthesiologists will have greater exposure in the cost category in the future when CMS includes costs related to episodes of care such as surgeries.
  • Exemption for Extreme and Uncontrollable Circumstances: CMS recognizes that public health emergencies and natural disasters, including the recent hurricanes, have impeded many physicians’ participation in the QPP. Clinicians in affected areas are eligible for an automatic exemption.

It is obvious that anesthetists and physicians in general, need to focus on effective quality data capturing and reporting early in the year. Partnering with an efficient medical billing and coding company is a feasible option for providers to improve efficiency and optimize reimbursement in the dynamic healthcare landscape.

Coding for Neuraxial Labor Analgesia/Anesthesia

Neuraxial Labor Analgesia/Anesthesia is provided to ease a woman’s pain during labor and delivery and is administered by an anesthesiologist and/or CRNA. Anesthesiology medical coding for obstetrical procedures involves the base units, time units and modifying units. Let’s see how to report this service using CPT codes.

When the neuraxial labor analgesia/anesthesia is administered by an anesthesiologist or CRNA, the anesthesia code 01967 should be reported along with an appropriate modifier from the following list.

Modifiers Used by Anesthesiologists

  • AA: Anesthesia services performed personally by anesthesiologist
  • AD: Medical supervision by a physician (anesthesiologist); more than four concurrent anesthesia procedures
  • QK: Medical direction (supervision) of two, three or four concurrent anesthesia procedures
  • QY: Anesthesiologist medically directs one CRNA

Modifiers Used By CRNAs

  • QX: CRNA service with medical direction (supervision) by a physician
  • QZ: CRNA service without medical direction (supervision) by a physician

Anesthesia time should also be reported along with this code, and the time units are calculated in 30-minute increments.

For a cesarean delivery or cesarean hysterectomy following neuraxial labor analgesia, report codes 01968 or 01969 appropriately. Anesthesia time and modifiers are required in this case.

Use code 01996 for daily management of epidural or sub-arachnoid drug administration; anesthesia time and modifiers are not required for this code.

Here are the CPT codes that can be used to report neuraxial labor analgesia/anesthesia along with the code description, basic values and guidelines.

Code Description Basic Values Guidelines
01967

Neuraxial labor analgesia/anesthesia for planned vaginal delivery (this includes any repeat sub-arachnoid needle placement and drug injection and/or any necessary replacement of an epidural catheter during labor)

5

For each 30-minute increment of time, one unit is allowed

+ 01968

Anesthesia for cesarean delivery following neuraxial labor analgesia/anesthesia

(Use 01968 in conjunction with code 01967)

3

For each 15-minute increment of time, one unit is allowed

+01969

Anesthesia for cesarean hysterectomy following neuraxial labor analgesia/anesthesia

(Use 01969 in conjunction with code 01967)

5

For each 15-minute increment of time, one unit is allowed

01996

Daily management of epidural, not to include the day that the catheter is placed

N/A

No reimbursement can be received for the day on which the catheter is placed. Maximum three visits are allowed. Additional visits are reviewed for medical necessity.

62310-59 OR 62311-59

Single epidural injection for post-operative pain management

9
OR
8

Separate reimbursement can be received for post-operative injections given for pain management.

62318
OR
62319

Placement of epidural catheter for post-operative pain management

10
OR
9

9 or ten additional base units are allowed for epidural catheter placement for post-operative pain management. These codes should be billed only if the relevant procedure is performed under general anesthesia followed by catheter placement. They should not be billed in conjunction with any of the ASA codes mentioned above. Though modifier-59 is required for filing these codes, anesthesia modifiers and time are not needed.

Sometimes, the neuraxial labor analgesia/anesthesia is provided by one practitioner and the administration of anesthesia during cesarean delivery or cesarean hysterectomy is by another practitioner. In such cases, the correct code should be reported along with the appropriate modifier. The anesthesiologists can receive reimbursement for medical direction.

  • Suppose the neuraxial labor analgesia/anesthesia is personally performed by the anesthesiologist and the anesthesia for the cesarean delivery is provided by a CRNA while the anesthesiologist supervises (medically directs two CRNAs). The CRNA is employed by the practice same as that of the anesthesiologist. The following should be the codes.

    01967-AA
    01968-QK
    01968-QX

  • When the CRNA is not employed by the same practice as the anesthesiologist, the coding will be different. Take the case of neuraxial labor analgesia/anesthesia being personally performed by the anesthesiologist, and the anesthesia for cesarean delivery is provided by the CRNA while the anesthesiologist supervises (medically directs one CRNA). The coding would be:

    01967-AA
    01968-QY

  • In this case, the CRNA would file a separate claim, reporting the anesthesia administered for cesarean delivery only. Some insurers allow the CRNA in a case such as the above to report the “add-on” code 01968-QX as a standalone code on a separate claim without the code 01967. This policy change is applicable also to the “add-on” code 01969, which can be reported as a standalone code on a separate claim if applicable.

    CRNAs cannot use the code 01961-QX to report the administration of anesthesia during the cesarean delivery in the above mentioned instance.

  • In a case where the neuraxial labor analgesia/anesthesia is performed by a CRNA and the anesthesia for the cesarean delivery is performed by the supervising anesthesiologist (the CRNA is employed by the same practice as the anesthesiologist), medical direction is for one CRNA and the coding is as follows:

    01967-QX
    01967-QY
    01968-AA

Include only the anesthesia time for the labor on the line item for the neuraxial analgesia/anesthesia (01967). For the cesarean delivery (01968), include only the anesthesia time for the delivery on the line item.

As each insurance carrier would have individual guidelines for anesthesia billing and payment, it is prudent to seek help from an expert in anesthesia coding to report anesthesia services delivered for obstetrical procedures. Partnering with a professional medical billing and coding company having expertise in anesthesiology medical billing is a good option.

An Overview of Anesthesia Coding Challenges

Anesthesiology medical billing is not based on a fee-for-service payment like other medical specialties. Reimbursement for anesthesiologists depends on the base unit (how complicated the procedure was and how much skill it required), time unit (how much time was taken to provide anesthesia) and modifiers (any special conditions that affect anesthesia). Therefore, proper documentation is crucial for this specialty. Using a back-end billing software may be suitable for other medical specialties but it is not efficient for anesthesiology.  The major challenges associated with anesthesia medical coding are:

  • Report Time – Though most anesthesiologist know the start (when the anesthesia provider starts to prepare the patient for induction) and stop (personal attendance no longer needed) time for anesthesia, the relief time (two separate start/stop time reported when a physician hands over a case to another physician) sometimes adds confusion. Relief time should only be reported by the physician who had spent the most time with the patient, or who had initially started the case. This requires rounding the anesthesia time up or down. Physicians normally round the time to the nearest 5-minute increment however, Medicare requires the start/stop time to be reported to the nearest minute. The average time a physician can spend with a patient in the Post-anesthesia Care Unit (PACU) is seven minutes. If it is more than seven minutes at a large percentage, the auditor would deem it as a fraudulent practice unless there are evident documents supporting why the extra time taken. If any breaks occur during anesthesia care, the total anesthesia time should be reported as the sum of the continuous block of anesthesia care. Good documentation would include the blocks of time before and after the break.
  • Multiple Lumens Placement – Even though there is no separate payment for placing multiple lumens, there is an exception  if the anesthesiologist did a central venous pressure and a Swan-Ganz with two separate lines or two sticks and documented the line placements as well as monitoring. The time for the placement of post-operative block or invasive lines before administration of the primary anesthetic for the relevant surgery should not be billed. Services of this kind should be billed as a flat rate fee. Do not subtract the time for the placement of post-operative block or invasive lines after the administration.
  • Time for Invasive Line Placement – The time for the placement of blocks post surgery (invasive line or epidural catheter) and before anesthesia induction or after anesthesia emergence should not be included in the anesthesia time, even if the block placement involves sedation and monitoring. Alternatively, the time spent for the placement of blocks after anesthesia induction or after anesthesia emergence should not be subtracted from the reported anesthesia time. If the sedation is administered only for the block placement, that time should not be included in the reported anesthesia time. Epidurals, central line, arterial, regional blocks etc. should be coded and billed as separate procedures. Do not include them in the reported anesthesia time. Pain management services should be reported in conjunction with an operative anesthesia service.
  • Cancelled Cases – Cases cancelled before anesthesia induction should be reported with an accurate evaluation and management (E/M) code and proper reasoning (for instance, equipment not working). If a case is cancelled after induction, it should be reported with an appropriate modifier (-53 (discontinued procedure), -73 (discontinued before providing anesthesia), -74 (discontinued after anesthesia administration or after the procedure begins)) and time. Providers should check whether or not the insurers accept modifiers. If modifiers are not accepted then these, cases should be billed using the correct anesthesia code with full base units and total time reported. The reason for cancellation should be clearly documented as well.
  • Monitored Anesthesia Care (MAC) – When billing for MAC, special attention must be given to evaluate medical necessity. If a  patient were to lose  consciousness at any time, it would fall under general anesthesia, not MAC. Documentation is very critical in this case as local coverage determinations vary depending on specific carriers.
  • Medical Direction Documentation – If any of the seven steps for medical direction is not performed or a procedure which is not allowed under medical direction is performed, then it will be designated as medical supervision which will result in a lower reimbursement. The documentation should clearly specify what is done during medical direction. If inadequate medical direction documentation is found during Centers for Medicare and Medicaid Services (CMS) audits, the anesthesia practices will have to pay back the difference. The modifier QK (identify the physician’s medical direction of two three or four concurrent cases) and QY (identify physicians’ medical direction of one CRNA) should be also used appropriately.

In essence, it is imperative to clearly understand the policies and guidelines of carriers when coding and billing for Anesthesia services. It’s crucial to have in-depth knowledge about all evolving rules that apply to your specific locality to ensure accurate anesthesiology medical coding and billing.

Why Outsource Anesthesiology Medical Coding?

Coding for any specialty is a tedious affair and if the coder makes an unconscious error, it can lead to claim rejection and denied reimbursement. Expert handling of anesthesiology medical coding requires extensive experience in coding for the specialty, AAPC certification and knowledge and proficiency in the following areas:

  • ASA coding
  • CPT coding paradigm
  • Anesthesiology regulations
  • Obstetric and surgical coding rules
  • And more

Skills Required

The anesthesiology medical coder should be up-to-date in the following and other areas:

  • Changing regulations
  • Unbundling and bundling procedure modifications
  • Accurate Coding Initiatives
  • Federal/State government compliance problems
  • Payer specific requirements
  • HCPCS codes

He should know how to use advanced medical coding software and be capable of ensuring steady cash flow to the healthcare practice. Other requirements are HIPAA compliance, in-patient/hospital coding, superior QA, completion of coding on time, ability to use state-of-the-art technology and support of Medicare, Oxford, Medicaid, EMI, Aetna, United, GHI, Humana, BCBS, HIP and other key medical insurances.

Outsource and Gain

If you outsource anesthesiology coding to an established medical coding company, you can rest assured that they would satisy all the requirements mentioned above. Outsourcing would also help you save money because you wouldn’t have to spend money to set up equipment and employ or train new staff. Apart from the regular services, these are some of the additional medical coding services you can expect from your reliable outsourcing solution provider:

  • Temporary and ongoing coding coverage
  • Resolution of backlog situations
  • Coding compliance reviews