Anesthesia Basic Coding Guidelines Part-B

Central / Neuraxial- when the anesthesia is injected at CNS (Brain/spinal cord). Can be used as MAIN ANESTHESIA or as Post-Op block. 01230 ; 62324-59

A)EPIDURAL: Mostly used but not limited to Labor and Delivery procedures (L&D).

This is INJECTED through a catheter or long needle into “Epidural space”. “Epi” means “above”. This is given above the Duramater layer.

Great care needs to be taken to avoid puncturing the layer immediately below containing CSF under pressure.

Documentation in ASA record - EPIDURAL can be performed either as a SINGLE SHOT INJECTION (S.S.) or with a CONTINUOUS CATHETER (EPI CATH/CONT. CATH/C.C.) through which medication is given over a prolonged period of time.

Look for terms like “Catheter” / “at few cm deeper level inserted” / “Bolus” / “Tuohy Needle” / “Epidural Steroid Injection” (ESI) administered.

“Caudal epidural” / “Caudal injection” is also Epidural.

CSE - Combined Spinal & Epidural. Usually only the Epidural is coded here.

B)SPINAL:

Documentation in ASA record -SAB / Sub-Arachnoid Block / Spinal.

Look for regional drug names too.

• Deeper level anesthesia; more potent than Epidural.
• Used in knee, hip, Spinal and lower body parts surgeries. Used very frequently in C-section surgeries.
• Can be given at CERVICAL / LUMBAR / THORACIC level.

CERVICAL VERTEBRA - C1-C7 ; THORACIC - T1-T12 ; LUMBAR à L1-L5 ; SACRAL -S1-S5 ; COCCYGEAL - C1-C4 = Total 33.
        

The gap between two vertebra/Disc is called - INTERVERTEBRAL SPACE.

Coding can be done either based on VERTEBRA COUNTS or based on INTERVERTEBRAL SPACE (depends on the surgery and the CPT code).

C)PERIPHERAL NERVE BLOCK/ANESTHESIA - When regional anesthesia is injected at a nerve/location toward the periphery of the body, e.g. at extremities. 64K CPT.

• Can be SINGLE SHOT or CONTINUOUS CATHETER.
• Can be used as MAIN/SURGICAL ANESTHESIA or as POST-OP BLOCK.
• Block used for surgical anesthesia is basically the type of anesthesia and represented/reported by the appropriate ASA (anesthesia) code 00100-01999.
• Block used for post Operative pain purpose, administered by Anesthesia staff are considered as Anesthesia Ancilary services and are reported separately along with ASA codes with a modifier 59 and a Laterality modifier (LT/RT/50) as applicable.
• Details about P.O. blocks will be discussed in later section.

D)TIVA (Total Intravenous Anesthesia): A technique of general anesthesia which uses a combination of agents given exclusively by the intravenous route without the use of inhalation gas agents.
TIVA is considered as a separate TOA (type of anesthesia) and not exactly as General anesthesia.

E)Local /Topical Anesthesia: An anesthetic drug (which can be given as a shot, spray, or ointment) that numbs only a small, specific area of the body (for example, teeth/gum, foot, hand, or patch of skin). With local anesthesia, a person is awake or sedated, depending on what is needed. Local anesthesia lasts for a short period of time and is often used for minor outpatient procedures (when patients come in for surgery and can go home within a short span of time). For someone having outpatient surgery in a clinic or doctor's office (such as the dentist or dermatologist), this is probably the type of anesthetic used. The medicine used can numb the area during the procedure and for a short time afterwards to help control post-surgery discomfort. [LOCAL / TOPICAL ANESTHESIA Not reported/coded by anesthesia coders]

This is the “lightest” anesthesia type in terms of intensity.

Drugs generally used - Lidocaine, Xylocaine etc.

Surgeries Used in - Dental, small skin lesion removal etc.

F)Moderate / Conscious Sedation: This is “heavier” than local anesthesia, but lighter than MAC. There is no exact “level” or definition of this anesthesia type. Pt. remains conscious/awake and can communicate with doctor, and this is a light mode of sedation. Depending on Pt.’s level of consciousness, the sedation types may vary.

Surgeries Used in- Colonoscopy.

 

SERVICES THAT CAN BE REPORTED by ANESTHESIA CODER:

Any service performed by an ANESTHESIA TEAM STAFF (MD-A or MD Anesthesiologist, a CRNA or a CRNP) only can be billed, unless there is a prohibition to report.

Anesthesia coders MUST NOT report any service that’s performed by a non-anesthesia staff (surgeon/radiologist/ultrasound technician/lab technician/pathologist/ED Physician etc.).

Different types of services that are usually performed by ANESTHESIA STAFF -

Providing anesthesia service to render a patient sedated or to make unconscious during surgery.

Ancillary Services:

Line placements.
Post-operative pain mgt by giving pain blocks.
Ultrasound
Epidural Blood patch / BIS Monitoring / Emergency Intubation
CPR (Cardio Pulmonary Resuscitation)

LINE PLACEMENTS:

Lines could be divided in to - IV / Arterial line / CVP / Swan ganz or PA / TEE

IV lines - “Intravenous” line placement. This is generally an “inclusive” service of most anaesthesia techniques, hence usually NOT coded separately.

How to code: However this can be reported separately under UNUSUAL SITUATIONS, for example, when any of the following is documented (and of course performed by Anesthesia staff) 

• Difficult access / Multiple attempts / Hard Cath / Hard Stick .
• If no documentation of any of the above, IV is not codeable, unless there is client specification.
• Usually CPT 36000 / 36410 etc codes are used to report the service.
• Add modifier 59 with IV CPT code when reported along with an ASA code.

ARTERIAL LINE/CATHETER - Also called as “A-line” / “Art line”.

• A-line is mosty encountered in - Procedure on arteries (endarterectomies, bypass graft etc), procedure on brain, spinal fusion, heart and kidney procedures. It is often used for laparotomies or orthopedic procedures if required. [These procedure names are mere examples. There are no blanket rules in coding, it varies from chart to chart basis.]
• Done through ARTERIES – usually RADIAL ARTERY (hand) / FEMORAL ARTERY (groin).
• When two different A-lines are placed successfully then the second A-line is reported with modifier 76.
• Coded with CPT 36620. IN-SITU ….. is not billable.
• Mod. 59 not needed, even when reported with an ASA code.

CENTRAL VENOUS CATHETER/PLACEMENT (CVC / CVP) -

• When a monitoring catheter’s tip enters the central venous circulation, it’s a CVC/CVP.
• Also known as Central Line / Central Venous catheter / Central Venous Access Device or Catheter.
• Can be placed via PERIPHERAL VEINS in arms/groin (femoral vein) – called as PICC line (“Peripherally Inserted Central Line”).
• Can be inserted via CENTRALLY LOCATED VEINS at Neck (Internal Jugular Vein) / Chest (Subclavian vein or Axillary Vein).
• Used for administering medications, measure central venous pressure, obtain blood for tests etc.
• Documentation to Look for - CVC can be TUNNELED or NON-TUNNELED catheters.
• CVP/CVC check-box should be checked or noted.
•   Sometimes names of various types of CVC can be found – Hickman’s / Quinton / Groshong catheter.
• Coded with CPT 36556 / 36555 (age dependant). Mod. 59 not needed, even when reported with an ASA code.
• Mostly found in complex heart/brain/neuro surgeries.

SWAN-GANZ CATHETER / PULMONARY ARTERY CATHETER (SG or PA Cath) -

Swan-Ganz or Pulmonary Artery catheter (SG / PA) are mostly encountered in brain/heart procedures. It is often encountered with other procedures too.
SG/PA cath is introduced through a CVC only. Hence if a CVC is used only to introduce a SG cath and then the CVC is removed keeping the SG in place, then only the SG cath is coded, and NOT the CVC. If both CVP/CVC and SG are marked on the record, only SG/PA cath is reported.
If it’s specifically noted that one SG and CVC was used through a same route (vein) and then there was another CVC through another vein (where there was no SG), then for the first vein, code only the SG (because in same route you cannot code the CVC), and for the second vein, code the CVC.
Mostly found in complex heart/brain/neuro surgeries.
SG cath is coded with CPT 93503.

 


TRANS ESOPHAGEAL ECHOCARDIOGRAPHY (TEE) -

• TEE is most commonly encountered (as ancillary procedure) in heart procedures.
• Overall TEE procedure has 3 parts – Probe placement – Image Acquisition, Interpretation – Report. Usually anesthesia staff performs the placement only. Sometimes he can do all 3 steps.
• If only PLACEMENT is done by the ASA staff, report with CPT 93313. If other parts are done too, report CPT 93312. CPT 93312 needs mod 26.
• TEE is a different procedure from DOPPLER or TTE (Trans Thoracic Echocardiography) hence code carefully depending on documentation.