Anesthesia & Pain Management Coding Alert

The Coding Institute Anesthesia & Pain Management Coding Alert Your practical adviser for ethically optimizing coding, payment, and efficiency in anesthesia and pain management practices 2009, Vol. 11, No. 12 (Pages 89-96) What s Inside Curb Your Excitement Over Terminated Edits...91 Most CCI 15.3 deletions apply to non-covered procedures. News You Can Use: Implement Your Swan-Ganz Boost...92 Updated MPFS includes pay hike for catheter placement. Master Moderate Sedation Coding With These Easy Steps...92 CCI 15.3 will have you watching provider involvement and documentation. You Be the Coder...92 Learn Crosswalks for Endoscopy Procedures Reader Questions Study E/M Definitions for Counseling...94 62311 With 01992 Depends on Providers...94 Code 1 Level for 2 Medial Branch Nerve Injections...94 NovaSure Hysteroscopy Crosses to 00952...95 Follow These Examples for P Modifier Usage...95 Endoscopic Lumbar Nerve Decompression...95 Report J1885, 93672 for Toradol Injection...96 Capture TPIs With Injections and More, Thanks to Edit Reversals CCI 15.3 zeroes in on moderate sedation, but allows for more unbundling. The latest Correct Coding Initiative (CCI) edits delete previous CCI edits for many acute postoperative pain management codes, and change modifier indicators for some of the most common pain management procedures. CCI 15.3 went into effect Oct. 1 and includes thousands of new, swapped, and terminated code pairs you need to implement now in order to file the correct codes and get reimbursed accordingly. Clue In to Modifier Indicator Changes With Biggest Impact The big changes for anesthesia and pain management involve the change from a 0 modifier indicator to a 1 modifier indicator, says Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of MJH Consulting in Denver. Having a 1 modifier indicator means you can append a modifier and bypass the bundling edits, thus gaining clearance to report both procedures. Example: CCI 15.3 lists trigger point injections 20552 (Injection[s]; single or multiple trigger point[s], 1 or 2 muscle[s]) and 20553 ( single or multiple trigger point[s], 3 or more muscle[s]) as Column 1 codes. Now you can append modifiers to bypass the edits for trigger point injections and Column 2 codes representing some of your most common procedures: 62310 Injection, single (not via indwelling catheter), not including neurolytic substances, with or without contrast (for either localization or epidurography), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution) epidural or subarachnoid; cervical or thoracic 62311 lumbar, sacral (caudal) 64408 Injection, anesthetic agent; vagus nerve 64410 phrenic nerve 64435 paracervical (uterine) nerve. Faster filing: One important reminder is that the modifier must be appended to the Column 2 code and not the lower relative value unit (RVU) code, Hammer says. In the example above, the trigger point injection codes carry a lower RVU. If you append the modifier to the Column 1 code instead of the Column 2, however, the carrier will deny your claim. The change is retroactive back to April 1, 2009.

Other pairs with modifier indicator changes involve Column 1 codes 27096 (Injection procedure for sacroiliac joint, arthrography and/or anesthetic/steroid), 36557 (Insertion of tunneled centrally inserted central venous catheter, without subcutaneous port or pump; younger than 5 years of age), 36558 ( age 5 years or older), and 36560-36566 (Insertion of tunneled centrally inserted central venous access device ). All the modifier indicator changes are retroactive to April 1, 2009. Watch Your Moderate Sedation Opportunities CCI 15.3 includes 18,320 new edit pairs, according to a summary report by Frank Cohen, PA, of MIT Solutions Inc. in Clearwater, Fla. The overwhelming majority have a modifier indicator of 0, meaning you cannot use a modifier even if you think it is appropriate, Cohen stated in a press release. The most common codes being paired in new edits are for some moderate sedation services: 99148 Moderate sedation services (other than those services described by codes 00100-01999), provided by a physician other than the health care professional performing the diagnostic or therapeutic service that the sedation supports; younger than 5 years of age, first 30 minutes intra-service time 99149 age 5 years or older, first 30 minutes intra-service time +99150 each additional 15 minutes intraservice time (List separately in addition to code for primary service). Note that the majority of the new edits were for moderate sedation performed by another physician instead of the performing surgeon, Hammer says. These new bundling edits make sense that the physician reporting the surgical procedure code should not be able to report these particular moderate sedation codes that require a different provider performing the moderate sedation services. Pain practices: Anesthesiologists provide anesthesia during procedures, not moderate sedation which means you wouldn t be reporting 99148-99150 anyway. But you re in a different situation when coding pain management. Your pain management specialist becomes the surgeon when administering injections, so you might have reported moderate sedation for some procedures in the past. Switch the Codes in These Pairs As if keeping up with new edits isn t tricky enough, as an anesthesia or pain management coder you also have swapped edit pairs to change in your system. CONTACT INFORMATION We would love to hear from you. Please send your comments, questions, tips, cases and suggestions for articles related to anesthesia and pain management coding, reimbursement, or compliance to Leigh DeLozier, CPC, at leighd@eliresearch.com. Mail: PO Box 413006, Naples, FL 34101-3006 Phone: (800) 508-2582 Fax: (800) 508-2592 Editor: Leigh DeLozier, CPC (leighd@eliresearch.com) Consulting Editors: Scott Groudine, MD Marvel Hammer, RN, CPC, CCS-P, ACS-PM, CHCO Managing Editor: Mary Compton, PhD, CPC (maryc@eliresearch.com) Associate Publisher: Jeanne Caggiano (jeannec@eliresearch.com) Director of Development: Bridgett Hurley, JD, MA (bhg@eliresearch.com) President: Samantha Gardiner Saldukas (sam@medville.com) Director of Sales: Bill Streight (bills@medville.com) Medallion Group Manager: Bret Brockbank (bretb@eliresearch.com) Live Conference Manager: Mariangela Ruiz (mariangelar@eliresearch.com) Audioconference Director: Jeanne Horne (jeanneh@eliresearch.com) Anesthesia & Pain Management Coding Alert (print ISSN 1533-590X, online ISSN 1947-8704) (USPS # 019-444) is published monthly by The Coding Institute, a subsidiary of Eli Research, 2222 Sedwick Road, Durham, NC 27713. 2009 The Coding Institute. All rights reserved. Subscription price is $397. Periodicals postage is paid at Durham, NC, 27705 and additional entry offices. POSTMASTER: Send address changes to Anesthesia & Pain Management Coding Alert PO Box 413006, Naples, FL 34101-3006. Web: www.codinginstitute.com Customer Service: service@medville.com Discussion Group: www.coding911.com Rates: USA: 1 yr. $397; 2 yrs. $774 (save $20), 3 yrs. $1141 (save $50). Bulk prices available upon request. Credit Cards Accepted: Visa, MasterCard, American Express, Discover CPT codes, descriptions, and material only are copyright 2009 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS Restrictions Apply to Government Use. Anesthesia & Pain Management Coding Alert is independent and not affiliated with any organization, HMO, vendor, or company. Reasonable attempts have been made to provide accuracy in the content. Of necessity, however, examples cited and advice given in a national periodical such as this must be general in nature and may not apply to any particular case. Further, medical coding is part science, part art; even experts sometimes differ. Also, clinical and other circumstances may differ between cases and thereby affect coding. Thus, neither the publisher, editors, board members, contributors, nor consultants warrant or guarantee the information contained herein on coding or compliance will be applicable or appropriate in any particular situation. For information tailored to your specific circumstances, consult a qualified professional. Have information on copyright violations? Call us! We ll share with you 25% of the net proceeds of all awards related to copyright infringement that you bring to our attention. Contact Samantha Saldukas at (239) 280-2301, fax (239) 790-3803, or e-mail sam@medville.com. This publication has the prior approval of the American Academy of Professional Coders for 0.5 Continuing Education Units. Granting of this approval in no way constitutes endorsement by the Academy of the content. Call The Coding Institute at (800) 508-2582 for more information about how to receive your CEUs. The Coding Institute also publishes the following newsletters. Call (800) 508-2582 for free samples: Coding Monthlies: Cardiology Dermatology Emergency Medicine Family Practice Gastroenterology General Surgery Internal Medicine Neurology Neurosurgery Ob-Gyn Oncology & Hematology Ophthalmology Optometry Billing & Coding Orthopedics Otolaryngology Pathology/Lab Pediatrics Physical Medicine & Rehab Podiatry Pulmonology Radiology Urology Other Newsletters: Medical Office Billing & Collections Alert Medical Office Front Desk Pro Part B Insider Page 90 Get CPC certified in 4 days CodingCert.com 2009, Vol. 11, No. 12/Anesthesia & Pain Management Coding Alert

This part of CCI 15.3 includes common procedures, such as 64450 (Injection, anesthetic agent; other peripheral nerve or branch) with 20550 (Injection[s]; single tendon sheath, or ligament, aponeurosis [e.g., plantar fascia ]). The Column 1 and Column 2 designations for the affected pairs have flip-flopped, so pay special attention to which procedure is now comprehensive versus component. This is a really important point, Hammer notes. If the provider puts the modifier on the Column 1 code in error, the Medicare contractor will deny the Column 2 code and not allow processing for payment. Example: Previous CCI edits listed 20550 in Column 1 and 64450 in Column 2. CCI 15.3 reverses those places, with 64450 in Column 1 and 20550 in Column 2, back to an effective date of Jan. 1, 1996. Check Out the CMS Explanation Niles R. Rosen, MD, medical director of the National Correct Coding Initiative, wrote the American Society of Anesthesiologists on behalf of CMS, explaining the Oct. 1 CCI changes before they went into effect. Highlights of the letter included: CMS will modify the edits bundling epidural injection and nerve block CPT codes into certain injection/aspiration procedures (CPT codes 20550-20553, 20600-20612, and 27096) so that all edits will allow use of NCCI-associated modifiers. If a provider performs a nerve block or epidural injection unrelated to anesthesia for one of the other listed procedures, the epidural injection or nerve block code may be reported with an NCCI-associated modifier. CMS will modify the edits bundling epidural injection and nerve block CPT codes into insertion of tunneled centrally inserted central venous access/catheter procedures (CPT codes 36557-36566) so that all edits will allow use of NCCI-associated modifiers. CMS will modify the edit with column one CPT code 62270 and column 2 code 62310 to allow use of NCCI associated modifiers. CMS will delete the edits bundling epidural injection and nerve block codes into CPT codes 31500, 36555, 36556, 36568, 36569, 36620, 36625, 93503, 93561, and 93562. Full details: You can read the complete letter on the ASA s website (www.asahq.org). Simply click on Practice Management to reach the latest ASA news and scroll down to ASA wins reconsideration of CCI edits dated July 2, 2009 Curb Your Excitement Over Terminated Edits Most CCI 15.3 deletions apply to non-covered procedures. At first glance, one bright spot in Correct Coding Initiative (CCI) version 15.3 could be the list of terminated code pairs, especially if your pain management provider performs IDET but don t get too excited too soon. The report terminates many previous coding pair edits associated with code 22526 (Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; single level) including: Many somatic nerve injection procedures (64400-64483) All sympathetic nerve injections (64505-64530) Transesophageal echocardiography monitoring (93318, Echocardiography, transesophageal [TEE] for monitoring purposes, including probe placement, real time 2-dimensional image acquisition and interpretation leading to ongoing [continuous] assessment of [dynamically changing] cardiac pumping function and to therapeutic measures on an immediate time basis). CCI 15.3 indicates that you can code for these paired procedures retroactive to April 1, 2009 but there s a catch. Thermal intradiscal procedures, including IDET, are non-covered effective Sept. 28, 2008, based on a Medicare National Coverage Determination (NCD) policy, says Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of MJH Consulting in Denver. It isn t necessary to have CCI edits if the Column 1 code is not covered, so the bundling edit deletions make sense. Anesthesia & Pain Management Coding Alert/2009, Vol. 11, No. 12 To subscribe, call (800) 508-2582 Page 91

News You Can Use: Implement Your Swan-Ganz Boost Updated MPFS includes pay hike for catheter placement. The October update to the 2009 Medicare Physician Fee Schedule (MPFS) database included good news for anesthesiologists: an increase in practice expense relative value units (RVUs) for 93503 (Insertion and placement of flow directed catheter [e.g., Swan-Ganz] for monitoring purposes). The increase applies only when your anesthesiologist places the Swan-Ganz for monitoring purposes in a facility setting, but don t let that bother you. A Swan- Ganz catheter placement is a highly invasive procedure usually performed for patients requiring intensive care, says Scott Groudine, MD, professor of anesthesiology at Albany Medical Center in New York. A facility setting would be the only appropriate location. The change went into effect Oct. 5 and bumped the RVUs from 0.00 to 0.75. That means reimbursement of $139.23 for 93503, an increase of approximately $27.05 (before geographic adjustments). CMS says the change is effective for services provided on and after Jan. 1, 2009. Next steps: Getting the extra reimbursement is up to you, because payers are not required to review their files and pay past claims. CMS has instructed payers to adjust claims that are brought to their attention, however, so sift through your records and refile accordingly. Information: Read the transmittal at www.cms.hhs. gov/transmittals/downloads/r1810cp.pdf. You Be the Coder Learn Crosswalks for Endoscopy Procedures Question: Our group is looking to expand and start doing anesthesia for general and/or MAC anesthesia for colonoscopy, laparoscopic gallbladder, and EGD (Esophago-gastro duodenoscopy). What are the correct codes for these? Florida Subscriber Answer: Consider your answer carefully, then turn to page 95. Master Moderate Sedation Coding With These Easy Steps CCI 15.3 will have you watching provider involvement and documentation. Considering the heavy focus on moderate sedation in the latest round of Correct Coding Initiative (CCI) edits, every coder should be up to date on when and how to correctly report moderate sedation services. By focusing on the providers and documentation of their roles, you ll be on your way to claims success. Learn the Moderate Sedation Ground Rules It s easy to confuse the various levels of sedation your physician might provide, so start with the basics: Anesthesiologists don t provide moderate sedation. As the American Society of Anesthesiologists (ASA) points out, It is important to note that anesthesiologists provide anesthesia (0XXXX codes) services. The moderate sedation codes were developed for cases where nonanesthesiologist physicians sedate patients (December 2005 ASA newsletter). Your physician might provide moderate sedation under different circumstances. When an anesthesiologist is performing a nerve block/injection procedure, he or she is classified as the surgeon, says Joanne Mehmert, CPC, CCCPM, ACS-PM, of Joanne Mehmert and Associates in Kansas City, Mo. Once your provider shifts from an anesthesia provider role to the provider (or surgeon) performing the service, you re in the realm of moderate sedation. You still need a qualified independent observer present in addition to the physician completing the service. The same physician cannot safely sedate the patient, monitor his or her condition, and perform the diagnostic or therapeutic service. Another qualified observer must be present during the procedure to monitor the patient and assist in sedation services. Moderate sedation does not include minimal or deep sedation. CPT makes it clear that the moderate sedation codes are for sedation other than those described by the anesthesia codes, says Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, consulting manager for Pershing, Yoakley and Associates in Clearwater, Fla. Moderate sedation does not include minimal sedation (anxiolysis), deep sedation, or monitored anesthesia care (MAC). Page 92 Get CPC certified in 4 days CodingCert.com 2009, Vol. 11, No. 12/Anesthesia & Pain Management Coding Alert

Choose Code Family Based on Involvement CPT divides moderate sedation codes into two families. Both sets of codes are then further broken down based on the age of the patient and incremental time, Mac says. If the same physician provides moderate sedation and performs the procedure, choose from 99143-+99145 (Moderate sedation services [other than those services described by codes 00100-01999] provided by the same physician performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient s level of consciousness and physiological status ). For example, pain management providers often report 99144 in conjunction with injection procedures such as radiofrequency destruction 64622-64627 (Destruction by neurolytic agent, paravertebral facet joint nerve ). If different providers perform the service and oversee the moderate sedation, code from 99148-+99150 (Moderate sedation services [other than those services described by codes 00100-01999], provided by a physician other than the health care professional performing the diagnostic or therapeutic service that the sedation supports ) instead. You could possibly report these codes in addition to procedures, such as MRIs or spinal taps for children or other non-medicare patients (since CCI edits regarding moderate sedation might not affect reporting for non-medicare cases). 4 Final Tips Help Clarify Documentation Details Every detail supporting moderate sedation is crucial, considering how closely payers scrutinize the claims. Keep these final tips in mind before filing: Don t report moderate sedation when the procedure code has a bull s eye symbol beside it in the CPT manual (such as 22526-22527 for percutaneous intradiscal electrothermal annuloplasty, or IDET). For a quick look at procedures that include moderate sedation, see Appendix G in your CPT book. Because you re dealing with time-based codes, calculate the time correctly. Intraservice time requires the Newsletter Question or Comment? If you have a question or comment about the contents of this publication, please contact the editor, Leigh DeLozier, CPC, at leighd@eliresearch.com. surgeon s continuous face-to-face attendance, Mehmert says. Calculate the time from when the surgeon is present (when the sedation agent is administered) until the surgeon is no longer present. The nursing records and physician s report of service should document the time that the physician is personally present with the patient, Mehmert adds. Assign the correct add-on code when the service lasts longer than 30 minutes. Codes +99145 and +99150 have the same descriptor ending ( each additional 15 minutes intra-service time [List separately in addition to code for primary procedure]), so be sure to match the addon code with the appropriate base code. Check with your payer about moderate sedation reimbursement. Codes 99143-+99150 are still carrierpriced with no relative value units (RVUs) assigned, and there is no change in the proposed Medicare Physician Fee Schedule, Mehmert says. Some payers (such as Highmark Medicare) never allow separate payment for anesthesia service when the same physician furnishes the medical or surgical service. Translation: Payers set their own reimbursement for moderate sedation. Check your Medicare contractor s Web site for information so you ll know what to expect. Note: Looking for an easy way to distinguish the various levels of sedation? To receive an easy-to-follow comparison chart, email the editor (leighd@eliresearch. com) with Sedation Chart in the subject line. Get Ready For 2010 Coding Updates Prepare your entire staff for the 2010 overhaul of coding and billing changes in just 1 hour Soon you'll be working like crazy to make sure you're using the new codes correctly combing over the big, thick new CPT book for changes that are relevant to your specialty and trying to figure out reimbursement winners and losers after the changes come out. Are You Ready for All the Coding Changes? Don't get lost in the changes! Get up to speed with the new codes when you attend our audio conferences covering these specialties: Home Health Stark Clarification HIPAA Pulmonology Family Practice ORDER TODAY E/M coding update Radiology Pain Management Coding Updates And Other Specialities SAVE 10% OFF YOUR CODING UPDATE TODAY! 10% OFF Order Today Or Call 866-458-2965 for Details! Only on web orders. Login at http://www.audioeducator.com/page.php?page=cpt2010 Use Discount Code: PDI10 Anesthesia & Pain Management Coding Alert/2009, Vol. 11, No. 12 To subscribe, call (800) 508-2582 Page 93

READER QUESTIONS Study E/M Definitions for Counseling Question: An established patient came to our office to discuss results of a previous procedure. Our physician and the patient spend the majority of the 30 minute visit discussing the patient s response to the diagnostic injection, available treatment options, risks, and benefits. What s the correct level of E/M service to report? Washington Subscriber Answer: The history and exam key components are more than likely minimal in your case, but since counseling and coordination of care dominate the encounter, you can use time as the controlling factor in assigning the E/M service level if you have the appropriate documentation. If the supporting documentation includes both the total time of the visit and the amount of time spent in counseling and coordination of care and a brief summarization of the counseling, you may select the E/M code based on total visit time and report 99214 (Office or other outpatient visit for the evaluation and management of an established patient ), which specifies physicians typically spend 25 minutes face-to-face with the patient and/or family. Counseling includes the physician discussing with the patient and/or family one or more of several areas including diagnostic results, prognosis, risks and benefits of management (treatment) options, or importance of compliance with chosen management (treatment) options, according to the E/M services guidelines outlined in CPT. 62311 With 01992 Depends on Providers Question: Can I bill 01992 for anesthesia for 62311? California Subscriber Answer: It depends on who performed the epidural injection and who performed the anesthesia service. One physician cannot report both the anesthesia services and the surgical procedure if he performs the epidural injection (that becomes a case of conscious sedation instead of anesthesia administration). If two physicians participate in the procedure, report 62311 (Injection, single [not via indwelling catheter], not including neurolytic substances, with or without contrast [for either localization or epidurography], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or subarachnoid; lumbar, sacral [caudal]) for the physician administering the epidural injection. Then submit 01992 (Anesthesia for diagnostic or therapeutic nerve blocks and injections [when block or injection is performed by a different provider]; prone position) for the additional professional who provided anesthesia service during the injection procedure. Code 1 Level for 2 Medial Branch Nerve Injections Question: Our pain management specialist administered bilateral facet blocks to L3, L4, L5, and S1. How should I bill this to Medicare? Kentucky Subscriber Answer: Streamline your coding to: 64475 (Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; lumbar or sacral, single level) and modifier 50 (Bilateral procedure) to represent the L4-L5 spinal level innervated by L3 and L4 medial branches +64476 ( lumbar or sacral, each additional level [List separately in addition to code for primary procedure]) with modifier 50 for the L5-S1 spinal level innervated by the L4 medial branch and the L5 dorsal ramus. Why no extras: According to CPT Assistant September 2004, two medial branches block one spinal level, so you code one facet joint spinal level for every two medial branch nerves. In the past, some providers also thought there was a communicating branch from the S1 spinal nerve to the L5- Statement of Ownership, Management, and Circulation 1. Publication Title: Anesthesia & Pain Management Coding Alert 2. Publication Number: 019-444 3. Filing Date:10/1/09 4. Issue Frequency: Monthly 5. Number of Issues Published Annually: 12 6. Annual Subscription Price: $397 7. Complete Mailing Address: 2222 Sedwick Rd., Durham, NC 27713 Contact Person: Markie Farrell Telephone: (585) 657-4541 8. Complete Mailing Address of Headquarters: Same 9. Full names and complete mailing addresses for publisher, editor, and managing editor: Publisher: Samantha Saldukas, 2272 Airport Road S. Ste. 309, Naples, FL 34112-4803, Editor: Leigh DeLozier, (same address) Managing Editor: Deborah Dorton, JD, MA, CPC, (same address) 10. Owner: Eli Research, Inc., Greg Lindberg, 2272 Airport Road S., Ste., 309, Naples, FL 34112-4803 11. Issue Date for Circulation Data Below: October, 2009 12. 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S1 facet joint. Anatomic research has shown that as untrue. However, if physicians inject the S1 communicating branch, they are still blocking only the L5-S1 facet joint. You don t report additional units of service for the additional injection. Because of that, your provider blocked only two bilateral spinal levels, based on the information you share. NovaSure Hysteroscopy Crosses to 00952 Question: What surgical and anesthesia codes should I use for NovaSure? Montana Subscriber Answer: NovaSure is an ablation of the endometrial lining of the uterus. The surgical code is 58563 (Hysteroscopy, surgical; with endometrial ablation [e.g., endometrial resection, electrosurgical ablation, thermoablation]), which crosses to 00952 (Anesthesia for vaginal procedures [including biopsy of labia, vagina, cervix or endometrium]; hysteroscopy and/or hysterosalpingography). Follow These Examples for P Modifier Usage Question: What tips can you offer on distinguishing between CPT anesthesia physical status modifiers? Pennsylvania Subscriber Answer: The American Society of Anesthesiologists (ASA) doesn t fully define the physical status modifiers because their use is based on clinical decisions the anesthesia provider makes for each patient. Your provider assigns a physical status modifier during the preanesthesia assessment. Some physicians are better at documenting conditions to support physical status than others, but keep these examples in mind as a way to gauge your own cases: P1 (A normal healthy patient) is generally a healthy patient who presents with minimal risks. P2 (A patient with mild systemic disease) applies to patients with conditions such as controlled diabetes. P3 (A patient with severe systemic disease) points to conditions such as severe diabetes with vascular complications. P4 (A patient with severe systemic disease that is a constant threat to life) and P5 (A moribund patient who is not expected to survive without the operation) both represent very high risk, sick patients or those in trauma situations. Assigning physical status modifiers is very individualized and the information you find from one place to another might conflict. If you have questions, check with your anesthesiologist or nurse assistant for clarification. Endoscopic Lumbar Nerve Decompression Question: One of our physicians is looking into endoscopic lumbar spinal nerve decompression. One of the medical device representatives indicated he could bill it like the lateral extraforaminal approach for lumbar decompression, but I haven t found much information. What s your advice? Wyoming Subscriber Answer: Despite what you physician might have heard, your most appropriate choice probably is 64999 (Unlisted procedure, nervous system). Many pain management providers are being introduced to different endoscopic approach systems. The You Be the Coder (Continued on next page) (Question on page 92) Learn Crosswalks for Endoscopy Procedures Answer: The codes you ll need are: Colonoscopy: 00810 (Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum) Laparoscopy: 00790 (Anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; not otherwise specified) EGD: 00740 (Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum). Many carriers have special policies regarding reimbursement for anesthesia during endoscopy. Check with your local carriers to ensure your documentation supports what the insurer requires. Anesthesia & Pain Management Coding Alert/2009, Vol. 11, No. 12 To subscribe, call (800) 508-2582 Page 95

AMA confirms that the descriptors for lumbar decompression procedures, such as those mentioned to your physician (63055-+63057, Transpedicular approach with decompression of spinal cord, equina and/or nerve root[s] [e.g., herniated intervertebral disc], single segment ) do not include an endoscopic technique and should not be used to report this type of approach. If the provider doesn t complete the laminectomy (hemilaminectomy) required to meet the criteria for reporting 63020-+63035 (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intrevertebral disc, including open and endoscopically-assisted approaches ), the AMA directs you to report the unlisted procedure code. Report J1885, 96372 for Toradol Injection Question: How should I bill for an intramuscular injection of 60 mg of Toradol and calculate the medication units? Georgia Subscriber Answer: The correct procedure code is 96372 (Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular). Then report HCPCS code J1885 (Injection, ketorolac tromethamine, per 15 mg) for the medication. Because the descriptor specifies a medication amount, one unit equals 15 mg. To calculate the units, divide the total mg administered by 15. For example, in this case you ll bill with four units of service as your physician injected 60 mg of Toradol. SUBSCRIBE TODAY! Yes! Enter my one-year subscription to Anesthesia & Pain Management Coding Alert newsletter for just $397. Extend! I already subscribe. Extend my subscription one year for just $397. Name Title Office Address City St ZIP Phone E-mail Fax Online Version Available Payment Information: Check enclosed for $ (payable to The Coding Institute) Charge my credit card MC VISA AMEX DISC Exp. date Acct. # Answers to You Be the Coder and Reader Questions were provided by Scott Groudine, MD, an Albany, N.Y., anesthesiologist; and Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting in Denver. Subscription Version Options: (check one) Print Online* Both* (Add online to print subscription FREE) E-mail *(Must provide e-mail address to receive issue notification) Signature Bill me (please add $15 processing fee for all billed orders) P.O. Anesthesia & Pain Management Coding Alert The Coding Institute P.O. Box 933729 Atlanta, GA 31193-3729 Call (800) 508-2582 or Fax (800) 508-2592 E-mail: service@medville.com Editorial Advisory Board Lee S. Broadston President/CEO, BCS Inc., Minn. Patrick Cafferty, PA-C, MPAS Member, AMA Health Care President/CEO, Neurosurgical Associates of Western Kentucky Barbara J. Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CPC-I, CHCC President, CRN Healthcare Solutions, Tinton Falls, N.J. David Fugate, MS Executive Director Anesthesia Associates of Ann Arbor PC Leisa T. Gonnella, MHA Director of Administration Department of Anesthesiology University of Virginia Scott B. Groudine, MD Chair, Government, Legal and Economic Affairs Committee of the New York Anesthesia Society Professor of Anesthesiology Albany Medical Center, N.Y. Barbara J. Johnson, CPC, MPC Loma Linda University Anesthesiology Medical Group Inc. President, Real Code Inc., Calif. Janet McDiarmid, CMM, CPC, MPC CEO, McDiarmid Consultants LLC Past President American Academy of Professional Coders National Advisory Board Ron Nelson, PA-C Clinical Practitioner Reimbursement Policy Analyst President, Health Services Associates, Mich. Past President, American Academy of Physician Assistants Cindy Parman, CPC, CPC-H, RCC Principal and Co-Founder Coding Strategies Inc., Ga. AAPC National Advisory Board member Faculty Instructor, AMA Solutions Franz Ritucci, MD, DABAM, FAEP President, American Board of Ambulatory Medicine, Fla. Director, American Academy of Ambulatory Care, Fla. Lynn R. Rogers Office Manager Professional Economics Ltd., Ind. Member, Healthcare Billing and Management Association Teresa Ruiz-Law Independent Consultant Physician Groups Ltd., Ill. Susan L. Turney, MD, FACP Medical Director Reimbursement Marshfield Clinic, Wis. Linda R. Williams, CRNA, JD Past President, American Association of Nurse Anesthetists Attorney-at-Law and Medical-Legal Consultant Page 96 Get CPC certified in 4 days CodingCert.com 2009,Vol. 11, No. 12/Anesthesia & Pain Management Coding Alert