Briefing: Anesthesia Coding Date: 20 March 2007 Time:

Briefing: Anesthesia Coding Date: 20 March 2007 Time: 1610 - 1700
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CPT codes with their descriptions are copyrighted. For instance,
01967 – Neuraxial labor analgesia/anesthesia for planned vaginal delivery (this includes any repeat subarachnoid needle placement and drug injection and/or any necessary replacement of an epidural catheter during labor) Copyright CPT 2004 Always something to remember. It is okay to use the code. But when you match the code to the description – copyright. Track x – xxx day –

The anesthesia encounter coded the civilian way
Objectives The anesthesia encounter coded the civilian way The anesthesia encounter coded the military health system way for an ambulatory procedure visit (APV) anesthesia service How cosmetic surgery anesthesia services are currently billed in the MHS Why we don’t currently bill separately for inpatient surgeries SADR – Standard Ambulatory Data Record Track x – xxx day –

Overview Crosswalks Anesthesia Primer In the Weeds Modifiers Multiple procedures Post surgical anesthesia…

Making Life Easier – Crosswalks!
Available all over – use what is most comfortable for you In the Coding Compliance Editor In many desk references (just CPT code to anesthesia code) In cross coders and crosswalks Need to understand how they work to be sure to select the correct code

Anesthesia Coding Books
Crosswalk If you have the CPT code for the professional services, it will direct you the appropriate anesthesia code Frequently there will be alternates and you will have to select the correct one Some crosswalks have base units; some don’t Some crosswalks have CPT procedures, ICD-9 diagnoses, and ICD-9 procedures associated with the anesthesia code 01130 Anesthesia for body cast application or revision 29000 Application of halo type body cast 268.1 Rickets, late effect 93.51 Application of plaster jacket

Anesthesia Coding Books
Relative Value Guide List of base units in anesthesia code sequence Base units cover the pre-anesthesia assessment, special considerations during the anesthesia, such as fluid regulation and risk, and post anesthesia recovery You need base units when there are multiple procedures Base units also given for TIME from when anesthesia starts until patient released from anesthesia care Usually 15 minutes = 1 base unit

Anesthesiologist alone (AA) Payment of 100% of schedule
Anesthesia Modifiers Modifiers to indicate Anesthesiologist alone (AA) Payment of 100% of schedule Anesthesiologist directing another provider (QK) Don’t use with modifier QC Anesthesiologist supervising another provider (AD) CRNA directed or supervised by another (QX) CRNA receives up to 55% of what would have been paid if anesthesiologist or CRNA alone —Continued—

Anesthesia Modifiers Anesthesiologist medically directs one CRNA (QY) CRNA alone (QZ) Payment equals amount that would have been paid to anesthesiologist May have two different providers with same codes, only modifiers will be different Happens when there is direction or supervision

Anesthesia Modifiers G8 – Monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive surgical procedure G9 – Monitored anesthesia care (MAC) for patient who has history of severe cardiopulmonary condition QK – Medical direction of 2, 3 or 4 concurrent anesthesia procedures involving qualified individuals QS – Monitored anesthesia care (MAC) service (see G8 and G9) QX – CRNA service: with medical direction by a physician QY – Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist QZ – CRNA service without medical direction by a physician

Anesthesia Modifiers 23 – Unusual anesthesia (e.g., procedure when not usually done, such as for toddler or pt w/dementia or retardation or anesthesiologist performing supervision is present for induction) GC – Service performed in part by a resident under the direction of a teaching physician (do not use with GK) 47 – When anesthesia is done by the surgeon; would not be used with a code in the 0xxxx range Usually no additional reimbursement for this

Physical Status Anesthesia Modifiers
Unit Value P1 – Normal healthy patient P2 – Pt w/mild systemic disease P3 – Pt w/severe systemic disease 1 P4 – Pt w/severe systemic disease that is a constant threat to life P5 – Moribund pt not expected to survive w/o operation P6 – Declared brain-dead pt whose organs are being removed for donation 0 System will not permit these to be entered at this time. Usually found on the anesthesia report as ASA-1, etc. Be careful about organ harvesting, see code – Physiological support for harvesting of organ(s) from brain-dead patient. Track x – xxx day –

Anesthesia Primer Anesthesia – loss of feeling or sensation, particularly loss of sensation of pain General anesthesia – unconsciousness produced by anesthetic agent with lack of feeling over the entire body, with muscular relaxation Inhalation, IV, IM, suppository, or ingestion Regional anesthesia – interruption of sensory nerve conductivity from a particular region of the body (e.g., spinal, epidural) Field – using local anesthetic injections to produce walls of anesthesia encircling operative field Nerve – injection of anesthetic agent close to the nerve whose conductivity is to be silenced Bier’s block – local anesthesia produced by injection in the veins of a limb that has been rendered bloodless by elevation and construction

Regional Anesthesia (Spinal)
Spinal/Subarachnoid For pain control below the diaphragm (inject into cervical, thoracic, lumbar, or sacral subarachnoid space) Relaxes muscles Possible side effects – hypotension, nausea, vomiting, severe headaches Works more quickly than epidural, nerves in spine directly exposed to anesthetic If the anesthesia is done for OB, look at the 0196x codes. Spinals are often used for pain management. Pain management is not coded using the 0xxxx codes. If this is for pain control, but not with constant monitoring by anesthesia staff, use the following codes – do not use the 0xxxx codes single injections (based on location) continuous or intermittent bolus (based on location) For daily hospital management, use daily hospital management of...continuous drug administration. Remember, this is probably part of the global for the surgeon, so unless there is a really good reason and a request by the surgeon for anesthesia to do this, it should not be coded (it is part of the global). Track x – xxx day –

Regional Anesthesia (Epidural)
Inject agent in to thoracic or lumbar epidural space instead of the subarachnoid space Avoids headaches associated with spinal Possible side effects – bradycardia, respiratory depression, paralysis, hypotension, nausea, vomiting Just like spinals, if this is OB, look at the codes. If it is for pain management, look at the ;01996;62281,62282, ; codes. Track x – xxx day –

Anesthesiology Terminology
Add-on Codes Base Units Anesthesia Time Medical Direction Medical Supervision Monitored Anesthesia Moderate Sedation We are talking “General Anesthesia” here – not the pain relief stuff. Base units are usually one or two digits. Then frequently time is in units. Add both units together, multiply by the base charge (about $40/unit or so in the civilian sector) and presto – the cost for anesthesia. For instance, (with a “c” indicating inpatient only), appendectomy not done in conjunction with other intra-abdominal surgery, crosswalks to Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy, has a base unit of 6. Time is usually 90 minutes. If the insurance company bills units in 15 minute blocks, that is 6 more units. A total of 12 units. Multiple times the unit cost of $40. The anesthesia would cost $480 for the preoperative consult, the anesthesia, and post operative care. Sounds easy when someone says it, but here is the rest of the story, an explanation of base units, time, difference between direction and supervision, MCA, and CS. Track x – xxx day –

Exception to Single Anesthesia Code
Add-on codes are an exception to this policy Add-on codes are used when a basic procedure is a “batch” and additional units are a different size; “batch” Units are not a nice 1, 2, or 3 Add-on codes are listed in addition to the code for the primary procedure Only a few instances ALWAYS check the RVU guide to see if time is included on the add-on (e.g., OB) or in the base code (e.g., debridement) Track x – xxx day –

Add-On Anesthesia Codes
Base Code: Neuraxial labor analgesia/anesthesia for planned vaginal delivery (this includes any repeat subarachnoid needle placement and drug injection and/or any necessary replacement of an epidural catheter during labor) Anesth for c-section following neuraxial labor analgesia/anesthesia (must use with 01967) base units 3, plus time Anesth for c/section hysterectomy following neuraxial labor analgesia/anesthesia (must be used with 01967) base units 5, plus time The vaginal delivery anesthesia is a batch. When you start planning a vaginal delivery, and have that anesthesia, then to convert it to a C-section is an add-on batch. Then if you do a hysterectomy after the c-section, another batch. You would need to use 01967, and for the c-section hysterectomy after attempting a vaginal birth. Now, if you planned the C/S with hysterectomy, and did not have any anesthesia for a vaginal, totally different code – – Anes for C/S hysterectomy w/o any labor analgesia/anesthesia care. These are just the add on codes. When you see them in the book, they have the “+” and say they must be used with another code. Qualifying circumstances Under 1 or over 70 base 1 Total body hypothermia, base 5 Controlled hypotension, base 5 Emergency, base 2 Track x – xxx day –

Another Add-On Example
Anesthesia for 2nd and 3rd degree burn excision or debridement with or without skin grafting, any site, for total body surface area (TBSA) treated during anesthesia and surgery; less than 4% total body surface area base unit 3, plus time between 4 and 9% of total body surface area Base unit 5, plus time each additional 9% total body surface area or part thereof Base unit 1 (time is reported on 01952) List add-on codes separately in addition to code for primary procedure. Use in conjunction with code Time for additional TBSAs to be included in the time reported with 01952 Notice has no additional time. That is because all the extra time for more than 4% of total body surface area is collected with code Track x – xxx day –

Base Units …Any procedure around the head, neck or shoulder girdle, requiring field avoidance, or any procedure requiring a position other than supine or lithotomy, has a minimum Basic Value of 5.0 regardless of any lesser basic value assigned to such procedure in the body of the Relative Value Guide Field avoidance – when the anesthesia has to be done differently so the surgeons have space to work. If the anesthesia provider usually sits distal to the head, but the surgeon is working on the forehead, to avoid the surgical “field”, the anesthesia provider moves to the patient’s left side. Track x – xxx day –

Included in Basic Anesthesia Code
Preoperative and post-operative visits Administration of anesthetic Peripheral IV lines, administration of fluids and/or blood products incident to the procedure Interpretation of non-invasive monitoring (e.g., ECG, temperature, B/P, pulse ox, capnography, and mass spectrometry) Transportation, prepping, positioning, draping Laryngoscopy for placement of airway and placement Placement of nasogastric tube Interpretation of laboratory reports Nerve stimulation to determine level of consciousness For instance, the 20 base units associated with Anesthesia for heart transplant or heart/lung transplant include everything on this list Notice procedures NOT on the list – Swan-Ganz catheter placement and monitoring (93503)… Track x – xxx day –

Minutes – not 15 minute blocks
Anesthesia Time When anesthesia codes (based on location of surgery) are used, time is the unit of service Minutes – not 15 minute blocks Important to collect minutes as various insurers define “Block” differently Time involves continuous presence of anesthesia personnel Begins when the anesthesia personnel begin to ready the patient for anesthesia Ends when anesthesia personnel release the patient post anesthesia to recovery room personnel Unless there is an interruption Collecting minutes right now is not possible. When you enter a 0xxxx code, you may enter the modifier AA or QX, but it will jump right over the units field. I think this because, right now, the MHS “flat rate” bills anesthesia. That means, we bill say $731 for each anesthesia case, whether it took 10 minutes or 10 hours. - BUT, when we can collect minutes, say the case is 132 minutes, we will enter 132 minutes. This way, when the billers get the information, the biller can change the “units” to whatever “anesthesia unit” is used by that insurer. Track x – xxx day –

Civilian Sector Anesthesia Time
Find out how the payer wants time; lots of variation Minutes Blocks of 15 minutes, rounded to nearest tenth. For instance, 20 minutes = 1.3 blocks Blocks of 15 minutes, rounded to nearest 15. For instance, 7 minutes = round down, 8 minutes = round up Submit the bill the way the insurance company wants it – so the MHS collects minutes (in the units field) and when the bill goes out, it will be adjusted based on the insurer Insurers define how they want anesthesia units of time. Minutes – some insurance companies want us to submit the number of minutes. Some want us to submit in various “blocks” defined by them. Track x – xxx day –

7 Criteria of Medical Direction (modifier QK for anesthesiologist)
The anesthesiologist must: 1. Perform a pre-anesthesia exam and evaluation 2. Prescribe the anesthesia plan 3. Take part personally in the most demanding procedures of the anesthesia plan, including induction and emergence 4. Ensure that any procedures in the anesthesia plan that are performed by a qualified anesthetist 5. Monitor the course of the anesthesia administration at intervals 6. Be physically present and available for immediate diagnosis and treatment of emergencies 7. Provide the post-anesthesia care indicated Note: CRNAs so not code for medical supervision or medical direction. That is why the slide says “the anesthesiologist” Note: He/she – when speaking of a group of individuals, if even one in 1,999,999 is a male, the pronoun will be “he.” The pronoun “she” is only used of the entire group is feminine. Basically – the anesthesiologist is in charge, but there is a CRNA in the room. The CRNA will code doing the service with the entire time, using modifier QX. The anesthesiologist will code only for the time actually doing this case with the modifier QK. There may be two or three cases being directed, so be sure the anesthesiologist's minutes do not add up to more time than he was around. Track x – xxx day –

1. Address an emergency of short duration in the immediate area
6 Allowed Services While Directing Concurrent Anesthesia (modifier AD for the anesthesiologist) 1. Address an emergency of short duration in the immediate area 2. Administer an epidural or caudal anesthetic to ease labor pain 3. Perform periodic, rather than continuous, monitoring of an obstetrical patient 4. Receive patients entering the operating suite for the next surgery 5. Check on or discharge patients from the recovery room 6. Coordinate scheduling matters Obviously, if the anesthesiologist is off doing L&D anesthesia, you will not be collecting minutes of service for him on a case in the OR. Only the time actually spent with that specific patient may be coded to that patient. In most cases, the minutes of service for direction will be fewer than the minutes for that patient by the CRNA. Sooo, you say, what is the anesthesiologist getting out of doing all this direction as the minutes get divided up between the patients – remember the base units? T&A under 12 – anes base units 5 Cholecystectomy, open anes base units 7 Knee arthroscopy anes base units 4 Total: 16 base units plus time, instead of just doing the cholecystectomy for 7 base units plus time Each unit approximately $40, so by doing medical direction, an extra $360. Track x – xxx day –

Modifier QK for anesthesiologist, QX for CRNA
Medical Direction Modifier QK for anesthesiologist, QX for CRNA Anesthesiologist provides medical direction of 2, 3, or 4 concurrent anesthesia procedures involving qualified individuals (even an overlap of 1 minute counts as concurrent) Must meet 7 steps and not perform additional services other than the 6 allowed services Anesthesiologist codes with QK modifier CRNA codes with QX modifier The way we are currently suggesting this be coded is by using multiple SADRs. Surgeon has a SADR in the B**5 or A*** (inpatient) DO NOT CODE the Anesthesiologist doing direction or supervision. Anesthesiologist doing a case or a CRNA have a SADR in MEPRS BFAA. Current problem – we can not use the same code twice. But, if we have two anesthesia SADR, one for an anesthesiologist doing direction or supervision and one for the CRNA, it will look like there were two separate anesthesia encounters. Therefore, we will only code the individual doing the case, not the direction or supervision. We want it collected in BFAA so it does not artificially inflate RVUs and workload in the surgical specialties. This does cause a problem, because there is no way to match the surgical procedure with the anesthetic service when the two services are not collected in the same SADR. Billing will have to track down the surgical procedure from the surgeon’s bill and add it to the anesthesiology bill. Track x – xxx day –

Medical Direction of 1 CRNA
Anesthesiologist does medical direction of one CRNA Anesthesiologist codes with modifier QY on Anesthesiologist’s SADR CPT Descr Mod 1 Mod Unit 00790 Anes intraperi U abdomen QY CRNA codes with modifier QX on CRNA’s SADR 00790 Anes intraperi U abdomen QX P Surgeon codes with surgical procedure on surgeons SADR 47600 Cholecystectomy,open Notice, the anesthesiologist was not providing direction the entire time. Perhaps the anesthesiologist was doing scheduling tasks or taking care of an emergency in the area Track x – xxx day –

Medical Direction of 1 CRNA
Modifier QY for anesthesiologist, modifier QZ for CRNA Anesthesiologist directs qualified individual in 1 case, AND Anesthesiologist must meet the 7 steps of medical direction and not perform services other the 6 allowed services Track x – xxx day –

Medical Direction of 1 Resident
Anesthesiologist does medical direction of one Resident Anesthesiologist codes with modifier QC on Anesthesiologist’s SADR CPT Descr Mod 1 Mod Unit 00790 Anes intraperi U abdomen QC Resident is listed as additional provider on the aneshesiologist’s SADR Surgeon codes with surgical procedure on surgeon’s SADR 47600 Cholecystectomy,open Notice, the anesthesiologist was not providing direction the entire time. Perhaps the anesthesiologist was doing scheduling tasks or taking care of an emergency in the area Track x – xxx day –

Medical Supervision (anesthesiologist uses modifier AD)
Medical supervision by a physician, >4 concurrent anesthesia procedures Anesthesiologist codes with AD modifier Anesthesiologist receives 3 base units as compensation for preoperative services, plus 1 additional unit if present for induction (use modifier –23 to indicate presence at induction) Anesthesiologist medically supervises more than 4 concurrent anesthesia procedures (even an overlap of 1 minute counts as concurrent) Anesthesiologist fails to meet all 7 steps of medical direction SUPERVISION is not medical direction. It is VERY important to use the modifier AD as instead of getting base units and time, for this the anesthesiologist will only receive 3 base units. For supervision, the anesthesiologist need not be present at induction, unlike direction. Scenerio: Lady having bunionectomy. CRNA in room. Anesthesiologist zips in and does the injection, then zips out never to be seen again. Husband asks if CRNA could have done the injection. CRNA says yes, but that is just the way we do things here. What do you think is happening? Take part personally in the most demanding procedures of the anesthesia plan, including induction and emergence Track x – xxx day –

Anesthesia service performed personally by anesthesiologist
Performed By… Anesthesia service performed personally by anesthesiologist Anesthesiologist codes with AA modifier Anesthesiologist performs entire anesthesia service alone, OR Anesthesiologist is teaching physician and works with one intern or resident (modifier QC), OR Anesthesiologist is continuously involved in a single case involving a student nurse anesthetist CRNA service w/o medical direction by physician CRNA codes with QZ modifier Anesthesiologist not involved (in CRNA’s portion of care). CRNA works under supervision of surgeon Expect to see these on weekends when surgical teams are called in. As there is only one case going, why have two anesthesia personnel? Track x – xxx day –

Monitored Anesthesia Care (MAC)
When a patient receives local or no anesthesia but an anesthesia provider does a pre-operative assessment, is there during the procedure to monitor the patient and administer anesthetics if required, and does post-operative services as required (continuous monitoring) MAC provider must have training and experience involving: Patient assessment Continuous evaluation and monitoring of patient physiological functions Diagnosis and treatment (both pharmacological and non-pharmacological) of any and all deviations in physiological functions MAC is not when one provider does a diagnostic or therapeutic nerve block/injection and then the CRNA does the anesthesia care – see codes 01991/2 Track x – xxx day –

Individual must be continuously present to use these modifiers Monitor to anticipate need for general anesthesia, Treat adverse physiologic reactions such as hypotension, excessive pain, difficulty breathing, arrhythmias, adverse drug reactions… Track x – xxx day –

Code with the appropriate anesthesia location code and time G8 – Monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive surgical procedure G9 – Monitored anesthesia care for patient who has history of severe cardiopulmonary condition QS – Monitored anesthesia care Track x – xxx day –

Other Coding on APV SADR
Field Block Frequently used at end of surgical procedure to manage postoperative pain for 6-8 hours Multiple injections of local anesthetic (e.g., Marcaine) Need to have documentation in chart by the surgeon requesting a field block, or the block is part of the anesthesia package

Coding Anesthesia in MHS
Issues: MHS coding guidance does not reflect anesthesia coding in the civilian sector Not yet possible to have the same code twice on one SADR, (e.g., 00300AD, 00300QX) linked to two different providers Modifiers do not currently go forward in SADR If both CRNA and Anesthesiologist code (medical direction and actual administration) – looks like two FULL cases But, could feed TPOCS

1. Presurgical Anesthesia Review
If the patient is evaluated and it is determined that the patient should not have anesthesia, code based on documentation If there is a request for consult, and the anesthesia provider returns a written consult, then code as a consult If there is no written request for consult, code as a referral If the patient is determined to be an anesthesia candidate, it is included in the anesthesia package. It should be documented and coded using in the D-MEPRS with a V-code for pre-surgical consult

2. Anesthesia Provider Determine who was the anesthesia provider. This will be the provider for which there will be a SADR If there is an anesthesiologist doing medical direction or medical supervision, it will not be collected at this time. This is because the modifiers are not available. If both the direction and supervision and the anesthesia provision were coded, it will look like two entire anesthesia episodes occurred

3. Create SADR Someone will need to create a SADR in MEPRS DFAA Appointment type: PROC Provider: Anesthesia Provider Additional Provider: If medical direction or supervision, enter anesthesiologist’s name Additional Provider: Enter the lead surgeon’s name

4. Code SADR – Diagnoses Identify the primary diagnosis and code Identify the additional diagnoses and underlying conditions (such as severe systemic issues, particularly impacting the lungs) that impact the provision of anesthesia, and code

4. Code SADR – E&M Field The computer program requires an E&M code from the numbers in the “E&M” field There is no applicable code for anesthesia from , so enter the MHS placeholder code for this field of “99499”

4. Code SADR – Procedure Identify the all the surgical procedures Identify the anesthesia code to match the procedures (crosswalk is VERY helpful) Check the base units of all the procedures Code the procedure with the highest base unit Code add-on codes (if applicable) Calculate the number of minutes of anesthesia service Enter minutes in the units field (cannot do this right now, need to let it autofill with 1 – we are working to open the units field)

4. Code SADR – Procedure If the surgeon requested (in writing) a field block for post-anesthesia pain control, code it If the anesthesiologist did other codable procedure (e.g., special invasive monitoring, Swan Ganz), code it

Do NOT Code Included in basic code Preoperative and post-operative visits Peripheral IV lines, administration of fluids or blood products incident to the procedure Interpretation of non-invasive monitoring (e.g., ECG, temperature, B/P, pulse ox, capnography, and mass spectrometry) Transportation, prepping, positioning, draping Laryngoscopy for placement of airway and placement Interpretations of labs Nerve stimulation to determine level of consciousness

If there were additional considerations, code them
4. Code SADR – Procedure If there were additional considerations, code them Was patient of extreme age (<1 yr or > 70 yr)? 99100 Was total body hypothermia used? Was controlled hypotension used? Was it an emergency? If there had been a delay, would there have been a significant increase in the threat to life or body part? Our system will not accept the Physical Status modifiers right now. Frequently you see them on the CRNA’s or anesthesiologist’s documentation as ASA-1. The ASA stands for Am Society of Anesthesiologists. Track x – xxx day –

5. Considerations There is currently no way to override base units if the base unit is fewer than 5 (regarding cases requiring head, neck or shoulder girdle, requiring field avoidance, or any procedure requiring a position other than supine or lithotomy positioning) Base units will be automatically assigned according to the code for billing

6. Drugs Do not code anesthetic agents, antibiotics, anti-emetics or any other pharmaceuticals used during the case. These costs are already in the pharmacy stepdown in MEPRS and included in the calculation of the institutional component

Non-APV Coding – Anesthesia Coding
You may code inpatient anesthesia on the same SADR as the attending IF it is a SADR in the A-MEPRS Do not code anesthesia for inpatients in the DFAA MEPRS Some Servcies collect anesthesia in the D-MEPRS for outpatient – there would be no way to identify inpatient from outpatient if both were collected in the DFAA

Non-Ambulatory Patient Visit
Don’t use 0xxxx codes for pain relief provided by non-anesthesia providers Nerve blocks in the office by the orthopedic surgeon Local anesthesia Topical anesthesia Conscious sedation Nitrous oxide Don’t use 0xxxx codes for pain relief by anesthesia providers Pain clinic For the “pain relief” care, usually you will be coding a nerve block or some other injection. This does not involve constant monitoring. Frequently the patient comes in, gets the injection, leaves and has a level of pain relief for up to a number of weeks. Track x – xxx day –

Non-Ambulatory Patient Visit
Hints: Who did it? An anesthesia provider? This would be unusual. If the patient has a problem such that a privileged anesthesia provider needs to furnish the anesthesia, it is probably 0xxxx code (MAC is for a more serious patient than conscious sedation) An oral surgeon? Probably not anesthesia code (look at the anesthesia codes in D-HCPCS or conscious sedation) Level of consciousness? Patient loses reflexes and is not responsive to verbal stimuli, probably 0xxxx Patient still responsive, consider conscious sedation

Non-Ambulatory Patient Visit –
Regional Anesthesia & Peripheral Nerve Block Regional Spinal (low spinal, saddle block) Epidural (caudal) Nerve block (retrobulbar, brachial plexus block, etc.) Field block Regional – blocks painful sensation by targeting the nerves, not the brain. Peripheral nerve blocks are a type of regional block. Sometimes a sedative is given prior to administration, such as Valium. Don’t code the Valium; it is part of the institutional cost Track x – xxx day –

Regional Anesthesia & Peripheral Nerve Block
Other Stuff Regional Anesthesia & Peripheral Nerve Block Peripheral Nerve Blocks – Used to anesthetize individual nerves or nerve plexuses Agent is injected along the nerve, not in the nerve Metacarpal and digital nerve blocks are part of the surgical package and not coded separately When a nerve block is used in the OR with constant monitoring by the anesthesiologist or CRNA, use the 0xxxx codes When a nerve block is done in the clinic for long-term pain relief, use the Track x – xxx day –

Regional Anesthesia (IV Regional Block, Field Block)
Other Stuff Regional Anesthesia (IV Regional Block, Field Block) Intravenous Regional Block Pneumatic tourniquet to limb Inject distal to tourniquet Field Block Frequently used at end of surgical procedure to manage postoperative pain for 6-8 hours Multiple injections of local anesthetic (e.g., Marcaine) If the field block is done by the anesthesia staff at the end to manage postop pain, separately from the general anesthesia, it should be coded separately from the 0xxxx code. Track x – xxx day –

Other Stuff – Code Separately
Pain management and nerve blocks (if done at the end for post-operative pain management, separately from the anesthesia for the actual procedure) , 20526, , , 27096, , 62270, , , , 63650, , , , , 72275, 73542, Invasive Monitoring deleted, , 36580, 36584, , 93503 Transesophageal echocardiography Neurological monitoring 95955 Assign the codes. If there were different surgical procedures done, say a person was in a car accident, not wearing a seatbelt, and after a short flying lesson, rearranged her face on the pavement. Closed treatment of nasal septal fracture, with or without stabilization 21343 Open treatment of depressed frontal sinus fracture 11012 Debridement including removal of foreign material associated with open fracture(s), skin, subQ, muscle fascia, muscle, and bone 12055 Layer closure of wounds of face, ears, eyelids, nose, lips and /or mucous membranes; 12.6 to 20.0 cm Code Anes code Base Units time time time time Pick the one with 5 that is the most important, say Open treatment of depressed frontal sinus fracture. Use the anesthesia code. Put all the time against that code. Track x – xxx day –

Nerve blocks in the office by the orthopedic surgeon Local anesthesia
More Basics Don’t use 0xxxx codes for pain relief provided by non-anesthesia providers Nerve blocks in the office by the orthopedic surgeon Local anesthesia Topical anesthesia Conscious sedation Nitrous oxide Don’t use 0xxxx codes for pain relief by anesthesia providers Pain clinic For the “pain relief” care, usually you will be coding a nerve block or some other injection. This does not involve constant monitoring. Frequently the patient comes in, gets the injection, leaves and has a level of pain relief for up to a number of weeks. Track x – xxx day –

Moderate Sedation Medically controlled state of depressed consciousness while maintaining the patient’s airway, protective reflexes, and ability to respond to stimulation or verbal commands – Moderate sedation Moderate sedation is NOT anesthesia Moderate sedation billed as part of surgeon’s bill There would not be a separate anesthesia bill Patient still feels things, but not painful Patient able to respond to direction Patient does not require medically supervised recovery

Moderate Sedation 99143 – Moderate sedation done by surgeon; patient younger than 5 years; for initial 30 minutes 99144 – 5 years or older; initial 30 minutes – Each additional 15 minutes 99148 – Moderate done by someone other than the surgeon; patient younger than 5 years; for initial 30 minutes 99149 – 5 years or older; initial 30 minutes – Each additional 15 minutes

How to Code Anesthesia – Review
Determine post-surgical diagnosis (-es) Determine surgical procedure (and collect additional information such as body site, was it an emergency, CPR, post-surgical pain management) NOTE: You will not enter the surgical procedure on the SADR for the anesthesia – you just need it to determine the most appropriate anesthesia code Determine the anesthesia provider and minutes of service Look up the procedure codes in the Crosswalk Check base units in the Relative Value Guide Code the anesthesia procedure with the highest base units Match to diagnosis(es) Induction – sodium barbital and nabulon, halothon, narcan Track x – xxx day –

Code in Addition: Unusual Monitoring
Post-operative pain management on day after surgery If done by surgeon, it is included in Global Surgical Package Needs surgeon’s note reflecting request for anesthesia pain management services for epidural or subarachnoid pain management for the 1st day; for subsequent days (a single daily charge) Patient-controlled analgesia, per day (a single daily charge) – Insert central venous catheter – Insert intra-arterial catheter 93503 – Insert Swan-Ganz Patient controlled analgesia, per day (a single daily charge) Don’t know if this code is available in CHCS. But, if it is AND the surgeon ordered it, then it may be coded. It is not a CPT code, and is usually considered part of nursing duties. Coded bottom 3 bullets if done any time. Track x – xxx day –

Surgeon Does Anesthesia
When a surgeon administers and manages the anesthesia and does the surgery, add the modifier –47 to the surgical procedure. Do not code using the codes from

Pre-anesthesia Visit – Usually a Few Days Prior to Surgery
Coding E/M Prior Pre-anesthesia Visit – Usually a Few Days Prior to Surgery If the anesthesia is administered, the pre-anesthesia visit is included in the anesthesia administration code If the surgery is cancelled because of the anesthesia visit or other reason prior to induction of anesthesia, the pre-anesthesia visit should be coded based on the history, exam, and decision making, usually as a consult If the surgery is cancelled the “morning of,” but the anesthesiologist showed up—sorry, don’t code anything at this time (but still code the pre-anesthesia visit as an E/M) Last bullet – the anesthesiologist is caring for the patient, not providing advice, so it would be an initial new office for the visit prior to the day of surgery. It was not a consult, it would have been a referral for anesthesia care. Track x – xxx day –

Other Fun Stuff – HCPCS Anesthesia
Dialysis A4736 Topical anesthetic, for dialysis, per gm A4737 Injectable anesthetic, for dialysis, per 10 ml Dental D9210 – Local anesthesia not in conjunction with operative or surgical procedures (see 90784) D9211 Regional block anesthesia (see 01995) D9212 Trigeminal division block anesthesia (see 64400) D9215 Local anesthesia (see 90784) D9220 Deep sedation/general anesthesia – first 30 min (see ) D9221 Deep sedation/general anesthesia – each addl 15 min D9230 Analgesia, anxiolysis, inhalation of nitrous oxide

Other Fun Stuff – HCPCS Anesthesia
Dental (continued) D9220 Deep sedation/general anesthesia – first 30 min (see ) D9221 Deep sedation/general anesthesia – each addl 15 min D9230 Analgesia, anxiolysis, inhalation of nitrous oxide D9241 IV conscious sedation/analgesia – first 30 minutes (see 90784, 99141) D9242 IV CS/analgesia – each addl 15 min D9248 Non-IV conscious sedation

Cosmetic Surgery Pretty much billed the same amount as would have been billed in civilian sector Billed in MSA module directly to patient using an Invoice & Receipt (I&R) itemized receipt Surgeon Professional Fee –100% for main procedures with 50% for each additional/bilateral Anesthesia based on time and base units for main procedure (additional time for additional procedures and bilateral not included) Institutional based on location (e.g., inpatient DRG, hospital operating room based on APC of main procedure, clinic operating room based on ASC of main procedure Patient pays in advance for entire cosmetic procedure as if it were the only procedure being done

Why Anesthesia for Inpatient Surgeries Is Not Billed Separately
Inpatient services are flat–rate billed based on the Diagnosis Related Group (DRG) The MTF Average Standardized Amount (ASA) is multiplied by the DRG Relative Weighted Product (RWP) The MTF average standardized amount (ASA) includes all inpatient costs, both professional and institutional ASA includes inpatient physical therapy, nutritional medicine 7% of the total ASA fee is the professional component (surgeon and anesthesia provider’s time)

Select the Anesthesia Encounter Coded the Civilian Way
Quiz Select the Anesthesia Encounter Coded the Civilian Way Procedure a. Code the supervision as one encounter. Code the actual provision of anesthesia care as a different encounter b. Code on the same encounter as the surgeon. Code the anesthesia service with the highest base units, enter “1” in the units field, use modifer AA, QX, QY or QZ c. Code separately from the surgeon. Code the same diagnoses, in the same order as used by the surgeon (and hope they are correct). Code for anesthesia service with highest base units, with number of minutes, and appropriate modifier. If there was supervision or direction, a second entry with the same CPT, but different modifier. Code P1-P6 with the individual actually doing the service (not doing supervision or direction) Diagnosis a. Code the diagnosis for the procedure with the highest base units first b. Code the same diagnoses, in the same order as used by the surgeon (and hope the surgeon’s coders were correct) Answer: civilian – procedure c. Diagnosis b. Track x – xxx day –

Quiz Select the anesthesia encounter coded the military health system
way for an ambulatory procedure visit (APV) anesthesia service Procedure a. Code the supervision as one encounter. Code the actual provision of anesthesia care as a different encounter b. Code on the same encounter as the surgeon. Code the anesthesia service with the highest base units, enter “1” in the units field, use modifer AA, QX, QY or QZ c. Code separately from the surgeon. Code the same diagnoses, in the same order as used by the surgeon (and hope they are correct). Code for anesthesia service with highest base units, with number of minutes, and appropriate modifier. If there was supervision or direction, a second entry with the same CPT, but different modifier. Code P1-P6 with the individual actually doing the service (not doing supervision or direction) Diagnosis a. Code the diagnosis for the procedure with the highest base units first b. Code the same diagnoses, in the same order as used by the surgeon (and hope the surgeon’s coders were correct) Military – procedure b. Diagnosis – b. Track x – xxx day –

Select how cosmetic surgery anesthesia services are currently billed
Quiz Select how cosmetic surgery anesthesia services are currently billed a. What! We bill anesthesia? b. On the CMS 1500 with the surgeon’s CPTs c. On the UB-92 with the 99199 d. On the ASA 5, a unique anesthesia bill just like the NCPDP v5.1 for pharmacy and the ADA form for dental e. On a CMS 1500, separate from the surgeon’s professional bill f. With both the anesthesiologist and CRNA on the same bill, whatever the number is… g. The cosmetic surgery estimator takes the average amount of time for the primary procedure, and adds 30 minutes to estimate the anesthesia time. The base units plus 15 minute time units are added together and multiplied by about $18/unit to determine the bill In the MHS, if it isn’t cosmetic – it should be on a CMS 1500 separate from the surgeon. This requires deleting the initial bill with both, and generating two separate bills. Whatever you do, it sure doesn’t belong on a UB92. If it is cosmetic, we have an estimator. The pricing is based on the usual time it takes to do the procedure, plus 30 minutes to estimate the difference between surgical time and anesthesia time. Then, the actual bill is based on base units and estimated time of the main procedure. Track x – xxx day –

Select why we don’t currently bill separately for inpatient surgeries
Quiz Select why we don’t currently bill separately for inpatient surgeries a. Because we don’t use anesthesia on inpatients b. Because we have way too much to code and not enough coders so this is one thing we decided to blow off c. Because the MHS codes the anesthesia services on the same encounter as the primary surgeon. The primary surgeon will be the attending. The attending encounter is coded in the “A” MEPRS, so it does not flow to billing d. Because it is part of the “D” MEPRS step down to the “A” MEPRS so the cost is already included in the flat rate we use to bill multiplied by the Relative Weighted Product of the DRG e. All the others sound too logical, so none of the above Track x – xxx day –

Briefing: Anesthesia Coding Date: 20 March 2007 Time:

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Briefing: Anesthesia Coding Date: 20 March 2007 Time:

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