1 Ten Steps to Coding Anesthesia Services AAPC National Conference Orlando, Florida April 2013 Chandra Stephenson, CPC, CPC-H, CPMA, CPC-I, CANPC, CEMC, CFPC, CGSC, CIMC, COSC
2 Disclaimer The information in this presentation was current at the time the presentation was complied and does not include specific payer policies or contract language. Always consult CPT, CMS, and your payers for specific guidance in reporting services. The views expressed in this presentation are simply my interpretations of information I have read, compiled and studied. Much of the information is directly from the AMA, ASA, AAPC, CMS literature and other reputable sources.
3 Objectives Coding Identify resources and documentation needed to code anesthesia services Establish a simple, structured process for coding anesthesia services Documentation Compliance Identify information needed to code anesthesia services routinely missing from the medical record Identify ASA documentation requirements anesthesia providers and coders need to know
4 Types of Anesthesia Topical infiltration Local anesthesia Metacarpal/Metatarsal/Digital blocks ==================================== Regional anesthesia Peripheral nerve blocks Epidural or spinal anesthesia Monitored anesthesia care (MAC) General anesthesia
5 Levels of Sedation Responsiveness Minimal Sedation Anxiolysis Normal response to verbal stimulation Moderate Sedation/ Analgesia Purposeful** response to verbal or tactile stimulation Airway Unaffected No intervention required Spontaneous Ventilation Cardiovascular Function Deep Sedation/ Analgesia Purposeful** response following repeated or painful stimulation Intervention may be required Unaffected Adequate May be inadequate Unaffected Usually maintained Usually maintained General Anesthesia Unarousable even with painful stimulus Intervention often required Frequently inadequate May be impaired ASA Continuum of Depth of Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia
6 Who Makes the Rules? AMA American Medical Association ASA American Society of Anesthesiologists CMS Center for Medicare and Medicaid Services
7 ASA Standards Provide rules or minimum requirements for clinical practice Guidelines Systematically developed recommendations that assist the practitioner and patient in making decisions about health care Statements Represent the opinions, beliefs, and best medical judgments of the House of Delegates Guidelines-and-Statements.aspx
8 Resources Needed CPT book ICD-9-CM book HCPCS book ASA Crosswalk ASA Relative Value Guide
9 ASA Resources Relative Value Guide (RVG) Numeric value assigned to a procedure in relation to other procedures in terms of work and cost (similar to RVUs) Base Units Anesthesia Crosswalk Links surgical procedure(s) performed to the appropriate anesthesia service code
10 Documentation Needed Pre-anesthesia record completed by the anesthesia provider Anesthesia report completed by the anesthesia provider Post-anesthesia record completed by the anesthesia provider and the postanesthesia care unit (PACU) team Surgeon s operative report
13 What s Included? Pre-operative and post-operative visit General or regional anesthesia and patient care Administration of fluids and/or blood Usual monitoring services (eg, ECG, temperature, blood pressure, oximetry, capnography, and mass spectrometry)
14 Bundled Services Laryngoscopy (31505, 31515, 31527) Bronchoscopy (31622, 31645, 31646) Introduction of needle or catheter ( ) Venipuncture or transfusion ( ) Blood sample procurement through existing lines
16 Bundled Services (cont.) Retrobulbar injection (67500) Interpretation of lab tests ( , 82013, 82205, 82270, 82271) Injections and IV drug administration ( ) Esophageal, gastric intubation (91000, 91055, 91105)
17 Bundled Services (cont.) Injection of diagnostic or therapeutic substances ( , ) Nerve blocks ( ) Transesophageal echo (TEE) ( ) Each of the three services listed above may be separately reportable in certain circumstances. In those circumstances, modifier 59 should be appended to the CPT code for the procedure(s) performed.
18 10 Steps 1. Determine the appropriate CPT code(s) for the surgical procedure(s) performed. 2. Crosswalk the CPT code(s) to the appropriate ASA code. 3. Determine the appropriate number of base units. 4. Determine the appropriate number of time units. 5. Assign the appropriate modifier to identify the anesthesia provider.
19 10 Steps (cont.) 6. Assign the appropriate modifier to identify MAC services, when appropriate. 7. Assign the appropriate physical status modifier. 8. If applicable, assign the appropriate qualifying circumstance code(s). 9. Determine the appropriate CPT code(s) for any additional services or procedures performed. 10.Determine the total units for the anesthesia services.
21 Step 1: CPT Code for Procedure Surgeon performs an excision of a benign tumor on the olecranon process CPT Code: 24120
22 Multiple Procedures Crosswalk all surgical procedures performed Select the anesthesia code with the highest base units value Only one ASA code is reported Report the total anesthesia time
23 Step 2: Crosswalk Surgeon performs an excision of a benign tumor on the olecranon process CPT Code: CPT ASA Units TM Anesthesia for open or surgical arthroscopic procedures of the elbow; not otherwise specified
24 Multiple Procedures Example Procedures Performed: Closed treatment of proximal fibula or shaft fracture CPT Code: ASA Crosswalk: ASA Base Units: 3 Revision of total hip arthroplasty CPT Code: ASA Crosswalk ASA Base Units: 10
25 Multiple Crosswalk Options Procedure: Coronary artery bypass, vein only (33510) ASA Crosswalk Options: Anesthesia for procedures on heart, pericardial sac, and great vessels of chest; with pump oxygenator, age 1 or older for all non-coronary bypass procedures or for reoperation for coronary bypass more than 1 month after original operation (Base = 20) Anesthesia for direct coronary artery bypass grafting; without pump oxygenator (Base = 25) Anesthesia for direct coronary artery bypass grafting; with pump oxygenator (Base = 18)
26 Step 3: Base Units ASA-RVG Base Unit Exceptions Procedures of the head, neck, or shoulder girdle requiring field avoidance Procedures performed in a position other than supine or lithotomy For either of the above circumstances, a minimum base unit of 5 should be used.
27 Patient Positions Lithotomy
28 Step 4: Time Units Anesthesia Time Begins: When the anesthesia provider prepares the patient for the induction of anesthesia in the operating room or equivalent area Ends: When the anesthesia provider is no longer in personal attendance (patient is safely placed under post-operative supervision)
29 Step 4: Time Units (cont.) AMA and ASA recommend that 1 unit of time is equal to 15 minutes of anesthesia time Time is rounded up to the next unit after 7 ½ minutes is reached. Some carriers, including Medicare, do not follow the above recommendation. Refer to your local payer contracts and policies for specific guidance for reporting time.
30 Step 4: Time Units (cont.) Medicare Requires the actual anesthesia time (total number of minutes) be reported in box 24G of the CMS-1500 claim form Computes time units as one unit per 15- minute time period and rounds time unit to one decimal place Minute Unit Minute Unit
31 Step 5: Anesthesia Provider Modifier AA Description Anesthesia services performed personally by anesthesiologist AD QK QY QX Medical supervision by a physician: more than four concurrent anesthesia procedures Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist CRNA service: with medical direction by a physician QZ CRNA service: without medical direction by a physician
32 Medicare and Medical Direction Qualified Individuals CRNAs AAs Interns Residents* Student nurse anesthetists
33 Medicare and Medical Direction 1. Perform pre-anesthetic exam and evaluation 2. Prescribe the anesthesia plan 3. Personally participate in the most demanding procedures in the anesthesia plan 4. Ensures procedures that are not personally performed are performed by a qualified individual 5. Monitors the course of anesthesia in frequent intervals 6. Remains physically present and available for emergencies 7. Provides indicated post-operative care
34 Teaching Physician Guidelines Teaching physician must: Be immediately to furnish services during the entire procedure Document Presence during all critical (or key) portions of the procedure Involvement in cases with residents Availability of another teaching anesthesiologist as necessary Report Modifier AA Modifier GC
35 Step 6: MAC Services Modifier QS Description Monitored anesthesia care service G8 G9 Monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive surgical procedure Monitored anesthesia care for patient who has history of severe cardiopulmonary condition If a service is intended to be MAC and at any point the patient is unable to control their own airway, the service is no longer considered a MAC service and should be reported as general anesthesia.
36 Step 7: Physical Status Modifier Description Base Unit Value P1 A normal health patient 0 P2 A patient with mild systemic disease 0 P3 A patient with severe systemic disease 1 P4 P5 P6 A patient with severe systemic disease that is a constant threat to life A moribund patient who is not expected to survive without the operation A declared brain-dead patient whose organs are being removed for donor purposes 2 3 0
37 Physical Status Mortality Rates ASA Physical Status Dripps et al 1961 Marx et al :9, : 1,013 1: 10, : 151 1: : 22 1: :11 1: 64 Introduction to Anesthesia Robert Dunning Dripps, James E. Eckenhoff, Leroy D. Vandam Saunders Publishing
38 Step 8: Qualifying Circumstances CPT Code Description Base Unit Value Anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure) Anesthesia complicated by utilization of total body hypothermia (List separately in addition to code for primary anesthesia procedure) Anesthesia complicated by utilization of controlled hypotension (List separately in addition to code for primary anesthesia procedure) Anesthesia complicated by emergency conditions (List separately in addition to code for primary anesthesia procedure)
39 99100 Exceptions Anesthesia for all procedures on the larynx and trachea in children younger than 1 year of age Anesthesia for procedures on heart, pericardial sac, and great vessels of chest; with pump oxygenator, younger than 1 year of age
40 99100 Exceptions (cont.) Anesthesia for hernia repairs in the lower abdomen not otherwise specified, younger than 1 year of age Anesthesia for hernia repairs in the lower abdomen not otherwise specified, infants younger than 37 weeks gestational age at birth and younger than 50 weeks gestational age at time of surgery
41 Step 9: Additional Procedures Insertion of central venous catheter ( , ) Insertion of an intra-arterial catheter ( ) Insertion of Swan-Ganz (93503) Transesophageal Echocardiography (TEE) ( ) Procedures performed for post-operative pain management
42 Line Placements When was the line placed? Who placed the line? Reportable by the anesthesia provider: The anesthesia provider Not reportable by the anesthesia provider: The surgeon Another provider Was the CVP used to thread the Swan-Ganz catheter? If so, only the Swan-Ganz is separately reportable How many lines are there?
43 Transesophageal Echocardiography Reportable by the anesthesia provider: When performed for diagnostic or therapeutic purposes and supported by the documentation Modifier 59 should be appended to the CPT code for the TEE
44 Post-Operative Pain Management Epidurals If epidural is route of administration for anesthesia, postoperative pain management is not separately reportable When separately reportable Based on spinal region Two types Single Injection ( )» is not appropriate Continuous Infusion or Intermittent Bolus ( )» Include catheter placement» Append modifier 59» Can report for subsequent daily hospital management Time placing the epidural must be carved out of the total anesthesia time
45 Spinal Anesthesia
46 Epidurals Needles Catheters From Miller: Miller s Anesthesia, 6th ed.
48 Post-Operative Pain Management (cont.) Nerve Blocks If epidural is route of administration for anesthesia, post-operative pain management is not separately reportable When separately reportable Based on the nerve being blocked Single Injection Continuous Infusion by Catheter Brachial plexus, sciatic nerve, femoral nerve, lumbar plexus Time performing block must be carved out of the total anesthesia time
49 Spinal Blocks
50 Step 10: Total Anesthesia Units Medicare Base Value + Time Units = Total Units Other Payers* Base Value + Time Units + Modifying Units = Total Units *Verify your payers policies and contracts for specific guidance for proper determination of calculating units.
52 Exceptions Anesthesia for Obstetric Services Anesthesia for Burn Excisions or Debridement
53 Anesthesia for Obstetrics Base units plus time units (insertion through delivery), subject to a reasonable cap Base units plus one unit per hour for neuraxial analgesia management plus direct contact time (insertion, management of adverse effects, delivery, removal) Incremental time-based fees (eg, 0<2 hrs, 2-6 hrs, >6 hrs) Single fee
54 Anesthesia for Obstetrics Vaginal labor and delivery converted to a Cesarean delivery Only anesthesia scenario in which each of the services reported require base and time units to be calculated Vaginal labor and delivery: Time: Anesthesia start time through decision for C-Section Cesarean delivery following labor analgesia: Time: Decision for C-Section through anesthesia end time
55 Anesthesia for Burn Excisions or Debridement Second- or third-degree burns treated during anesthesia and surgery Based on total body surface area (TBSA) 01951: less than 4% total body surface area 01951: 4% to 9% total body surface area or part thereof : each additional 9% total body surface area or part thereof
58 Safe Conduct Anesthesiologist directing the team is responsible for: Management of personnel Preanesthetic evaluation of the patient Prescribing the anesthetic plan Management of the anesthetic Postanesthesia care Postanesthetic complications Anesthesia consultation
59 Preanesthesia Documentation Patient interview, including Patient identification Procedure identification Verification of admission status Medical history Anesthetic history Medication and allergy history NPO status Assess aspects of patient s physical condition that might affect decisions regarding perioperative risk and management
60 Preanesthesia Documentation (cont.) Appropriate physical examination, including Vital signs Airway assessment Review of objective diagnostic data Review of available medical record Formulation of the anesthetic plan and discussion of the risks and benefits of the plan (including discharge issues when indicated) with the patient or the patient s legal representative and/or escort Records an assessment (diagnosis) Documentation of appropriate informed consent(s)
61 Preanesthesia Documentation (cont.) When applicable/indicated Medical consultations Assignment of ASA physical status, including emergent status when applicable Appropriate premedication and prophylactic antibiotic administrations
62 Preanesthesia Documentation (cont.) If the patient is a minor or is unable to communicate, this should be reflected in the documentation as should the source of the information obtained
63 Intra-operative Documentation Time-based record of events, including Immediate review prior to initiation of anesthetic procedures Patient re-evaluation Re-verification of NPO status Check of equipment Check of drugs supply Check of gas supply
64 Intra-operative Documentation (cont.) Technique used Patient position(s) Any unusual events during the administration of anesthesia Status of the patient at the conclusion of anesthesia
65 Intra-operative Documentation (cont.) Monitoring of the patient Oxygenation Ventilation Circulation Body Temperature Doses of drugs and agents used Times of administration Routes of administration Any adverse reactions
66 Intra-operative Documentation (cont.) Type of IV fluids used* Amounts of IV fluids used Times of IV fluid administration Intravenous/Intravascular lines inserted Technique for insertion Location Airway devices inserted Technique for insertion Location *IV fluids includes blood and blood products
67 Postanesthesia Documentation Anesthesia provider Patient evaluation on admission to post anesthesia care unit (PACU) Anesthesia provider/pacu Nurse Patient evaluation on discharge from PACU Any unusual events during the administration of anesthesia Postanesthesia visits
68 Postanesthesia Documentation (cont.) Anesthesia provider/pacu Nurse Time-based record of Vital signs Level of consciousness Drugs administered Dosage Route of administration Type of IV fluids used Amounts of IV fluids used
69 Resources Utilized 2013 CPT Professional Edition 2012 ICD-9-CM 2013 HCPCS Level II 2013 ASA Relative Value Guide 2013 ASA Crosswalk 2013 Coding and Payment Guide for Anesthesia Services CMS Claims Processing Manual, Chapter 12, Section 50 ASA Standards Guidelines and Statements The Anesthesia Care Team (2009) Documentation of Anesthesia Care (2008) Basic Standards for Preanesthesia Care (2009) Standards for Postanesthesia Care (2009)
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