Advanced Anesthesia Presented by: Shelly Cronin, CPC, CPMA, CANPC, CGSC, CGIC 1 Agenda Understanding key terms Review coding concepts & modifiers Documentation standards How to avoid coding pitfalls New 2010 Anesthesia Teaching guidelines from Medicare 2 1
Understanding Key Terms General Local Techniques include Surface Infiltration Field block Peripheral nerve blocks Plexus Regional Techniques include Caudal or Saddle block Epidural Single or continuous Spinal Intravenous or Bier block Monitored Anesthesia Care (MAC) 3 Anesthesia Surgical Package Pre and post op visits Type of anesthesia Patient care during procedure Administration of fluids and/or blood products EKGs, temperatures, blood pressure Laryngoscopies & Bronchoscopies Introductions of a needle or catheter Venipuncture Blood samples via existing line Otolaryngology services CPR 4 2
Anesthesia Surgical Package Temporary pacemakers (transcutaneous) Cardioversion Cardiovascular stress tests Injections of diagnostic or therapeutic substances Interpretation of lab tests Injections IV drug administration Esophageal or gastric intubation Transesophageal Echocardiography (TEE) 5 The Manuals American Society of Anesthesiologist (ASA) Crosswalk & Relative Value Guide (RVG) CPT Current Procedural Terminology ICD-9-CM 6 3
Time Time starts when patient is prepared for anesthesia care Time ends when the anesthesiologist is not personally required to be in attendance Do not stop and start time when placing invasive lines 7 Concurrent Care Defined by CMS as concurrency is defined with regard to the maximum number of procedures that the physician is medically directing within the context of a single procedure and whether these other procedures overlap each other. 8 4
Physical Status Modifiers P1 healthy patient P2 mild systemic disease P3 severe systemic disease P4 severe systemic disease w/constant threat to life P5 moribund patient who s not expect to live without operation P6 declared brain dead, for organ harvest 9 Modifiers AA Personally performed by a physician AD Medical supervision by a physician for more than 4 concurrent anesthesia procedures G8 Applicable to Monitored Anesthesia Care (MAC) for deep, complex, complicated, or markedly invasive surgical procedures G9 MAC for patient who has history of severe cardiopulmonary condition QK (Used by physician) Physician medically directed 2 to 4 concurrent anesthesia procedures 10 5
Modifiers QS MAC services QX (used by CRNA) CRNA was medically directed by a physician (in one, two, three or four cases) QY (used by physician) Anesthesiologist medically directed CRNA in a single case QZ CRNA without medical direction GC These services have been performed by a resident under the direction of a teaching physician. 11 Modifiers 23 Unusual anesthesia 53 Discontinued Procedure 52 Reduced services 59 Distinct Procedural Service 12 6
Canceled Procedures What can you bill for and under what circumstances? Pre-op exam is performed but the patient has not been prepared for surgery Bill E/M code dependant on the location of the patient either inpatient or outpatient 99231 99233 (inpatient), 99212 99215 (outpatient) Patient prepared for surgery but prior to induction Some Medicare carriers will reimburse for 3 base units for the procedure Cancelled after induction (intubation) Use the code for the intended procedure with full base and time then append a 53 modifier 13 Invasive Lines Intra-arterial line (A line) Central Venous line (CVP) Swan-Ganz line or Pulmonary Artery line 14 7
Arterial Lines Codes 36620; arterial catheterization or cannulation for sampling, monitoring or transfusion 36625; cutdown for placement of A-line Allows constant monitoring of blood pressure during the procedure Documentation must support 15 Central Venous Pressure Line Codes 36555 -Insertion of non-tunneled centrally inserted central venous catheter; under 5 years of age 36565 - Insertion of non-tunneled centrally inserted central venous catheter; age 5 years and older allow physicians to have a direct measurement of the blood pressure in the right atrium of the heart and the vena cava (the vein connected to that chamber) 16 8
Swan-Ganz Pulmonary Artery Catheter 93503 insertion and placement of a flow-directed catheter for monitoring purposes (e.g. Swan-Ganz) A balloon-tipped line that allows physicians to measure blood pressure and cardiac output and sample blood directly from the heart chambers Referred to alternately documentation as a PA or Swan-Ganz catheter 17 Swan-Ganz vs. Right Heart Cath Inserted in same spot RHC is diagnostic test to detect signs of congestive heart failure and right heart valve disease Swan-Ganz PA catheter is for intraoperative monitoring purposes RHC reimbursed at higher rate than PA catheter 18 9
Invasive Lines Do s and Don ts Don't bill the CVP as CPT 36010. That code is for introduction of catheter for superior or inferior vena cava. Don't bill separately for a CVP port used to thread a Swan-Ganz catheter. It is okay to bill both a CVP and a Swan-Ganz if they are two separate lines. Don't confuse a CVP with a tunneled CVP [when catheter is subcutaneously tunneled prior to entry into vein (36557-36558)] which is placed for longterm use, not monitoring. Make sure you do not confuse the Swan-Ganz PA catheter and a Right Heart Catheter All invasive lines are flat fee surgical services (that is, you bill the surgical code, not the anesthesia code when you insert a line). You may not bill time with them. However, this does not mean you must stop and restart your anesthesia time while inserting them. 19 Invasive Lines Do s and Don ts You should not have to use modifier 59 for the line code separately with anesthesia, but some individual payers may require it Don't add an anesthesia "performance" modifier to these codes (e.g. AA or QZ). There is no separate payment for multiple lumens. You may place these lines prior to surgery, but do not bill time for that placement. Your documentation must show that the anesthesia provider actually placed the line if you are to bill for it. Merely checking a box that says "A-line," or "CVP" is not enough. If a checkbox doesn't spell out that you actually placed a line, an auditor might conclude that you merely monitored it and that's not a separately billable service. 20 10
Transesophageal Echocardiography (TEE) TEE is an invasive procedure in which a transducer is placed on the tip of an endoscope and inserted into the patient's esophagus to record a two-dimensional echocardiograph Purpose To provide excellent definition of heart structures. To view a heart difficult to examine using conventional echocardiography (for example, if the patient is obese or has a thick chest wall). To monitor heart function during cardiac surgery. To detect blood clots in the left atrium. 21 Transesophageal Echocardiography (TEE) 93312 is for TEE real time with image documentation (2D) with or without M-mode recording); including probe placement, image acquisition, interpretation and report. 93313 placement of transesophageal probe only. 93314 image acquisition, interpretation and report only. 93315 TEE for congenital cardiac anomalies; including probe placement, image acquisition, interpretation and report. 93316 placement of probe only for congenital cardiac anomalies. 93317 interpretation and report only for congenital cardiac anomalies. 93318 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. 22 11
Transesophageal Echocardiography (TEE) & CCI payable for an anesthesiologist to perform "intraoperative diagnostic" TEE "when the surgical procedure is expected to alter the anatomy and function of the cardiac or thoracic structures: If the evaluation of cardiac function and/or thoracic structures is necessary for the safe conduct of anesthesia or surgery. If the surgical technique will be affected by the intra-operative TEE findings, thus assisting in surgical management decisions. If thoracic structures and/or cardiac function were not adequately evaluated pre-operatively AND the information is necessary for the safe conduct of anesthesia and surgery." 23 TEE Documentation Basic Elements required Interpretation Clinical documentation Permanent and accessible storage of pertinent images 24 12
Post-op pain blocks Prove medical necessity; Clearly document that the post-op pain block is separate from the operative anesthesia Provide detailed documentation of the reasons why the service should not be included in the global surgical package 25 Post-op Pain Blocks Documentation tips Note service was specifically requested by the surgeon Time spent performing the block is separate from anesthesia time Attach modifier 59 Administration of block is clearly documented separately from the surgical anesthesia Use the appropriate pain diagnosis codes Document type of block, size of needle, type of drug, and if test dose was successful 26 13
Covered and Non-covered How to bill anesthesia when covered and noncovered are performed in the same operative session for Medicare patient s? Example Patient comes in for a cosmetic lipectomy (noncovered) at the same session as a breast reconstruction post-mastectomy (covered) Report charges as: 00402 (breast reconstruction) with base units(5) plus the time for the covered procedure 00802 (lipectomy) (bill time for this portion only to patient) 27 Covered and Non-covered What happens when a complication occurs from a non-covered procedure and the patient has to return to the OR? Medicare might cover if the patient suffers A post-operative infection that requires hospitalization Reversal of a intestinal bypass surgery for obesity Removal of a non-covered device Repair from complications from transsexual or cosmetic surgery Medicare will not cover anything deemed to be Not reasonable and necessary Anything that should be included in the surgical global fee 28 14
Diagnosis Coding What to do to ensure claims are not denied for medical necessity Document properly Specify the chief reason for the surgery Link the appropriate diagnosis code to the CPT procedural code Do not assign ICD-9 codes that are unrelated to the procedure that was performed Wait for the pathology report 29 Teaching Guidelines Old guidelines (prior to 1/1/2010) Teaching Anesthesiologist medically directing one anesthesia resident Fee based on fee schedule at full rate Teaching anesthesiologist medically directing two or more anesthesia resident Fee based on 50% on the fee schedule for the teaching physician 30 15
Teaching Guidelines New guidelines (after 1/1/2010) Teaching Anesthesiologist medically directing one or two concurrent cases Fees based on the regular fee schedule Teaching Anesthesiologist medically directing more than two concurrent cases Fees based under old guidelines 50% of fee schedule 31 Teaching Guidelines Teaching CRNA s Old guidelines (prior to 1/1/2010) not under medical direction, involved with one student nurse anesthetist or in two concurrent anesthesia cases involving student nurse anesthetists payment made at the regular fee schedule rate If the teaching CRNA, not under the medical direction, involved in two concurrent student nurse anesthetist cases Payment based on the full base units and partial time units 32 16
Teaching Guidelines Teaching CRNA s New guidelines (after 1/1/2010) Teaching CRNA s not under medical direction, in each of two concurrent cases with student nurse anesthetists can be paid the full fee 33 Teaching Guidelines Documentation changes Must prove that the teaching anesthesiologist was present with the resident during all critical or key portions of the service. CRNA s must prove that they were not under medical direction of an anesthesiologist Document the services provided by each provider 34 17
Reporting For new guidelines reporting is slightly different Use AA and GC to report cases when medically directing 1 or 2 residents, concurrent cases CRNA s report QZ w/documentation for their involvement in cases with SNA s 35 Summary Documentation is the key! Communication is required between coder and physician Proper coding and modifier use Knowledge of payer requirements 36 18
Resources 2010 CPT manual, Current Procedural Terminology, Professional Edition. AMA Press 2010 Centers for Medicare and Medicaid Services website at; http://www.cms.gov/ WPS Medicare website; http://www.wpsmedicare.com/ 37 CPT Copyright CPT copyright 2009 American Medical Association. All rights reserved. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. CPT is a registered trademark of the American Medical Association. 38 19