Coding and Payment Guide for Anesthesia Services. An essential coding, billing, and reimbursement resource for anesthesiology and pain management

Transcription

1 Coding and Payment Guide for Anesthesia Services An essential coding, billing, and reimbursement resource for anesthesiology and pain management

2 Contents Introduction... 1 Coding Systems... 1 Claim Forms... 2 Contents and Format of This Guide... 2 The Reimbursement Process... 3 Coverage Issues... 3 Payer Types... 3 Payment Methodologies... 5 Calculating Costs Other Factors Influencing Payment Correct Coding Policies for Anesthesia Services Workers Compensation Documentation An Overview Methods of Documentation General Guidelines for Documentation Principles of Documentation Fraud and Abuse Compliance Action Plan Claims Processing What to Include on Claims Clean Claims The Health Insurance Portability and Accountability Act Processing the Claim The Appeals Process Medicare Benefit Notices The CMS-1500 Claim Form The Electronic Claim Completion...57 The UB-04 Claim Form...65 Procedure Codes for Anesthesia Services...69 Structure the of CPT Book...69 CPT Coding Conventions...69 Unlisted Procedures...69 Modifiers...70 Payment for Anesthesia Services...71 Payment for Surgical Services and Procedures...71 Global Surgery Packages...72 Bundled Services Anesthesia...73 Procedure Code Listing...75 CPT Index ICD-9-CM Index ICD-9-CM Coding Conventions Coding Neoplasms Manifestation Codes Official ICD-9-CM Guidelines for Coding and Reporting ICD-9-CM Codes Medicare Official Regulatory Information Glossary Appendix A: Surgical to Anesthesia Code Crosswalk CPT Base Units Index CPT codes only 2009 American Medical Association. All Rights Reserved. Coding and Payment Guide for Anesthesia Services iii

3 report these codes if they elect not to participate. Category II codes are alphanumeric, consisting of four digits followed by an F and should never be used in lieu of a category I CPT code. This series of codes is updated on a biannual basis (January 1 and July 1), with codes that are released becoming effective six months later (e.g., codes released on January 1 become effective July 1). Refer to the AMA CPT website at for the most recent listing. Category III of the CPT coding system contains temporary tracking codes for new and emerging technologies that are meant to aid in the collection of data on these new services and procedures. Indicated by four numeric digits followed by a "T, like category II codes, category III CPT codes are released twice a year (January 1 and July 1) and can be found on the on the AMA CPT website. RVUs are not assigned for these codes, and payment is made at the discretion of the local payer. Once implemented, a service described by a category III CPT code may eventually become a category I code. HCPCS Level II Codes HCPCS Level II codes are commonly referred to as national codes or by the acronym HCPCS (Healthcare Common Procedure Coding System, pronounced hik-piks). HCPCS codes are used to bill Medicare and Medicaid patients and are also used by some third-party payers. HCPCS Level II codes, periodically updated and published annually by CMS, are intended to supplement the CPT coding system by including codes for nonphysician services, durable medical equipment (DME), and office supplies. These Level II codes consist of one alphabetic character (A through V) followed by four numbers. Claim Forms Institutional (facility) providers use the UB-04 claim form, also known as the CMS-1450, or the electronic 837i format to file a Medicare Part A claim to Medicare fiscal intermediaries (FI). Noninstitutional providers and suppliers (private practice or other health care providers offices) utilize the CMS-1500 form or the 837p electronic format to submit claims to Medicare contractors for Medicare Part B covered services. Medicare Part A coverage includes inpatient hospital, skilled nursing facilities (SNF), hospice, and home health. Medicare Part B coverage provides payment for medical supplies, physician, and outpatient services. Not all services rendered by a facility are inpatient services. Providers working in facilities routinely render services on an outpatient basis. Outpatient services are provided in settings that include rehabilitation centers, certified outpatient rehabilitation facilities, SNFs, and hospitals. Outpatient and partial hospitalization facility claims might be submitted on either a CMS-1500 or UB-04, depending on the payer. For professional component billing, most claims are filed using ICD-9-CM diagnosis codes to indicate the reason for the service, CPT codes to identify the service provided, and HCPCS Level II codes to report supplies on the CMS-1500 paper claim or the 837p electronic format. Contents and Format of This Guide The first three chapters following this introduction provide information regarding the reimbursement process, documentation, and claim completion, respectively. The fifth chapter, Procedure Codes for Anesthesia Services, contains a numeric listing of procedure codes. Each page identifies the information associated with that procedure including an explanation of the service, coding tips, associated diagnoses, related terms, Centers for Medicare and Medicaid Services (CMS) internet-only manual references that identify any official references found in the online CMS Manual System. The full excerpt from the online CMS Manual System pertaining to the reference is provided in the Medicare official regulatory chapter. The procedure code pages also have a list of codes from the official Centers for Medicare and Medicaid Services National Correct Coding Policy Manual for Part B Medicare Contractors that are considered to be an integral part of the comprehensive or mutually exclusive and should not be reported separately. Finally, all relative value information relevant to the code is listed at the bottom of the page. Following this chapter you will find a CPT procedure code index, an index of ICD-9-CM diagnosis codes for anesthesia services, and an index of HCPCS Level II codes for anesthesia services. Medicare Official Regulatory Information The full excerpts from the online online CMS Manual System pertaining to anesthesia are provided in this section. Since these excerpts often do not identify the guideline with corresponding CPT or HCPCS Level II codes our experts have crosswalked the appropriate reference, wherever possible, to the applicable procedure or supply code. This crosswalk reference is listed under each applicable CPT or HCPCS code in the definitions, guidelines, and index section. The excerpts are listed in this section in numeric order. Index and Appendixes The final section consists of a comprehensive index that provides a list of pages on which each term is discussed, and a glossary of coding, billing, and clinical terms applicable to your specialty. A listing of the Correct Coding Initiative (CCI) edits is provided to correspond with all of the CPT codes in the CPT definitions and guidelines section. CPT codes only 2009 American Medical Association. All Rights Reserved. 2 Introduction Coding and Payment Guide for Anesthesia Services

4 Anesthesia for procedures on salivary glands, including biopsy Coding Tips The appropriate modifier indicating the type of provider (i.e., physician, CRNA) as well as the type of service being rendered (i.e., personally performed, medical direction) should be appended to the procedure code. Modifiers indicating the physical status of the patient should also be appended when required by the third-party payer. Note that Medicare does not recognize physical status modifiers. Terms To Know biopsy. Tissue or fluid removed for diagnostic purposes through analysis of the cells in the biopsy material. ICD-9-CM Diagnostic Codes Malignant neoplasm of parotid gland Malignant neoplasm of submandibular gland Malignant neoplasm of sublingual gland Malignant neoplasm of other major salivary glands Malignant neoplasm of salivary gland, unspecified Malignant neoplasm of floor of mouth, part unspecified Secondary and unspecified malignant neoplasm of lymph nodes of head, face, and neck Secondary malignant neoplasm of other specified sites Benign neoplasm of major salivary glands Benign neoplasm of floor of mouth Benign neoplasm of other and unspecified parts of mouth Carcinoma in situ of lip, oral cavity, and pharynx Neoplasm of uncertain behavior of major salivary glands Neoplasm of uncertain behavior of lip, oral cavity, and pharynx Neoplasm of uncertain behavior, site unspecified Neoplasm of unspecified nature of digestive system Symptomatic inflammatory myopathy in diseases classified elsewhere (Code first underlying disease: 135, , , 446.0, 710.0, 710.1, 710.2, 714.0) Lung involvement in other diseases classified elsewhere (Use additional code to identify infectious organism. Code first underlying disease: 135, , 710.0, 710.2, 710.4) Hypertrophy of salivary gland Sialoadenitis Abscess of salivary gland Fistula of salivary gland Sialolithiasis Mucocele of salivary gland Disturbance of salivary secretion Other specified diseases of the salivary glands Cellulitis and abscess of oral soft tissues Work Value Non-Fac PE Fac PE V41.5 Sicca syndrome Congenital fistula of salivary gland Swelling, mass, or lump in head and neck Enlargement of lymph nodes Dysphagia, unspecified Dysphagia, oral phase Dysphagia, oropharyngeal phase Dysphagia, pharyngeal phase Dysphagia, pharyngoesophageal phase Other dysphagia Open wound of cheek, complicated Open wound of face, other and multiple sites, complicated Open wound of buccal mucosa, without mention of complication Open wound of mouth, other and multiple sites, without mention of complication Open wound of buccal mucosa, complicated Open wound of mouth, other and multiple sites, complicated Late effect of open wound of head, neck, and trunk Posttraumatic wound infection not elsewhere classified Persistent postoperative fistula, not elsewhere classified Problems with smell and taste IOM References 100-4,12,140; 100-4,12,140.2; 100-4,12, ; 100-4,12,30; 100-4,12,50; 100-4,3,100.2; 100-4,4,10.10; 100-4,4,10.4; 100-4,4,10.5; 100-4,4, ; 100-4,4, CCI Version T-0179T, 0180T, 01996, 31505, 31515, 31527, 31622, 31645, 36000, , , , 36440, 36600, 36640, 43752, 61026, 61055, , , , , 64470, 64475, 64479, 64483, , 64565, 67500, 76998, 81000, , 81005, 81015, 82013, 82205, 90865, 91000, 91055, 91105, , 92543, , , , , , , 93351, 93501, , 93701, , , 94002, 94004, 94200, 94250, 94640, 94644, , , , , 95819, 95822, 95829, , 96360, 96365, , , 99150, , , , 99315, 99318, , , , , , 99466, , C8921-C8927, G0380-G0384 Note: These CCI edits are used for Medicare. Other payers may reimburse on codes listed above. Malpractice Non-Fac Total Fac Total CPT only 2009 American Medical Association. All Rights Reserved. Coding and Payment Guide for Anesthesia Services Procedure Codes for Anesthesia Services 75

5 Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; subarachnoid epidural, cervical or thoracic epidural, lumbar, sacral (caudal) Explanation This procedure is performed to destroy nerve tissue or adhesions. The patient is placed in a spinal tap position. The site is sterilized, and the needle is inserted under fluoroscopic guidance. The needle is placed at the proper level and the neurolytic substance is administered. Once the injection/infusion is completed, the needle is removed and the wound dressed. Report if the substance is administered to the subarachnoid level. Report if the needle is inserted in the epidural region of a cervical or thoracic level. Report if the needle is inserted in the epidural region of a lumbar or sacral (caudal) level Disorders of sacrum Unspecified neuralgia, neuritis, and radiculitis IOM References 100-2,15,260; 100-4,12,30; 100-4,12,90.3; 100-4,14,10 CCI Version , 36000, , , 36440, 36600, 36640, 37202, 43752, , , , , 64479, 64483, , 69990, , 77002, , , 93318, 94002, 94200, 94250, , 94770, , 95819, 95822, 95829, 95955, 96360, 96365, 96372, , , Also not with 62280: 62284, , 64470, Also not with 62281: 62284, , 64470, 72275, J2001 Also not with 62282: , 62319, 64475, 72275, J2001 Note: These CCI edits are used for Medicare. Other payers may reimburse on codes listed above. Coding Tips As with all neurolytic injections, correct code assignment is dependent upon the type of injection. For this reason, the exact level and space of the injection should be verified in the medical record documentation. Injection of contrast is included and should not be reported separately. For fluoroscopic guidance and localization, see code Terms To Know adhesion. Abnormal fibrous connection between two structures, soft tissue or bony structures, that may occur as the result of surgery, infection, or trauma. dura mater. Outermost, hard, fibrous layer or membrane that surrounds the brain and spinal cord. subarachnoid. Located below the arachnoid meningeal layer. ICD-9-CM Diagnostic Codes Spasmodic torticollis (Use additional E code to identify drug, if drug-induced) Reflex sympathetic dystrophy of the lower limb Unspecified disorder of autonomic nervous system Multiple sclerosis Lumbosacral plexus lesions Lumbosacral root lesions, not elsewhere classified Causalgia of upper limb Mononeuritis multiplex Causalgia of lower limb Osteoarthrosis, unspecified whether generalized or localized, other specified sites Degeneration of lumbar or lumbosacral intervertebral disc Postlaminectomy syndrome, lumbar region Spinal stenosis of lumbar region Lumbago Sciatica Thoracic or lumbosacral neuritis or radiculitis, unspecified Work Value Non-Fac PE Fac PE Malpractice Non-Fac Total Fac Total Procedure Codes for Anesthesia Services CPT only 2009 American Medical Association. All Rights Reserved. Coding and Payment Guide for Anesthesia Services