Hit the ground running with these do’s and don’ts on anesthesia billing in the ED
If you’re having difficulty determining when to report conscious sedation and anesthesia in the emergency department (ED), keep your eyes open to these expert tips on how — and how not — to report these services.
DO report anesthesia codes — not conscious sedation codes — when the ED physician administers conscious sedation for another physician who’s performing surgery. You don’t need to meet a general anesthesia requirement to assign anesthesia codes, says Michael Granovsky, MD, CPC, FACEP, vice president of Medical Reimbursement Systems in Stoneham, Mass. “In fact, a majority of the cases [in the ED], although involving significant sedation, do not require that the patient be endotracheally intubated,” he says.
According to the American Medical Association, “If an anesthesiologist or other physician is administering the conscious sedation [for a physician performing the surgical procedure], then the appropriate code from the anesthesia section (00100-01999) should be reported by the other physician.”
CPT also supports this position in its description for the conscious sedation codes, says Michelle Bailot, CPC, medical coding specialist at SVA Healthcare Services.
“This scenario is common with orthotics, plastics and, potentially, one ED doc performing a deeper sedation in support of another ED physician,” Granovsky says. In the last situation, he says, you’ll have to meet minimum medical-necessity requirements for the involvement of both ED physicians.
DO request a copy of the flow sheet and physical exam, Bailot advises. The flow sheet will have records of all the medications the physician administered, the patient’s vital-sign updates, and the times that each of these was performed, she says. Many hospitals have a standardized flow sheet for use in the operating room, endoscopy area, and the ED. Generally, your physician is required to document a physical exam and relevant anesthesia-related history. Aphysical status modifier of P1-P5 should also be selected based on the patient’s condition.
In addition, “Both of these sheets should be signed by the physician actually monitoring the anesthesia. Typically, a nurse will be the one giving the doses, and he or she may have signed the sheet, but the physician will need to sign as well,” she says.
DON’T forget that when billing anesthesia, you must determine the appropriate anesthesia base units for the surgical procedure and then add the time units. Each code in the anesthesia section of CPT has a base unit value assigned by the American Society of Anesthesiology (ASA). These base units and time units do not appear in the CPT book, so additional materials are required for access to this information.
After you determine the number of base units for the particular procedure, you must then look at the amount of anesthesia time. The time that the patient is under sedation is frequently broken down into 15-minute increments, Bailot says, though some payers use 10-minute slots.
For example, suppose a non-emergency physician came to the ED to perform an incision and drainage procedure on a patient’s abdominal cyst. The ED physician administered the anesthesia for the surgery. In this case, you’d report code 00700 (Anesthesia for procedures on upper anterior abdominal wall; not otherwise specified), which has four base units plus time. The patient is “under anesthesia” for 30 minutes, so you would also add in two time units, for a total of six anesthesia units. Of note, CPT says the time starts when the anesthesiologist begins to prepare the patient for the induction of anesthesia, and ends when the physician is no longer in attendance.
DO follow this three-step process to report anesthesia services accurately, Granovsky suggests:
1. Take the dominant CPT code (usually representing the surgical procedure performed), and then determine the appropriate anesthesia code from the 00100-01999 section.
2. Using the ASA guidelines, determine the number of base units assigned to that anesthesia code.
3. Add in the time units reflected in the ED record, based on that particular payer’s increments (either 10 or 15 minutes, usually).
DON’T forget to apply one of these patient status modifiers when reporting anesthesia codes in the ED. Tell your physicians to document the patient’s condition in the record so you’ll know which one to choose:
•P1 — Normal healthy patient
•P2 — Patient with mild systemic disease
•P3 — Patient with severe systemic disease
•P4 — Patient with severe systemic disease that is a constant threat to life
•P5 — Moribund patient who is not expected to survive without the operation
•P6 — Declared brain-dead patient whose organs are being removed for donor purposes
These modifiers apply only to anesthesia codes — not to conscious sedation codes.
DO remember these seven guidelines when reporting conscious sedation codes:
•Conscious sedation codes are not restricted to being reported with any particular CPT code.
•Don’t report pulse oximetry separately from conscious sedation codes (on the professional side).
•Don’t report conscious sedation with anesthesia.
•If you’re reporting conscious sedation, a trained observer — typically a nurse — must have been present.
•Demerol and morphine, applied alone, usually do not constitute conscious sedation, although the physician may use them in addition to higher-level agents such as midazolam or ketamine.
•When reporting codes for orthopedic services with descriptions including “with” or “without anesthesia,” you should select “without anesthesia” when billing conscious sedation. “With anesthesia” applies to the operating room, not the ED.
•Don’t append modifier -47 (Anesthesia by surgeon) with conscious sedation codes.
CPT also includes several qualifying-circumstances codes that impact the character of the anesthesia the physician provided. You may use more than one of these qualifying-circumstances codes per claim, and they have their own assigned base and time units. In the ED, adding code +99140 (Anesthesia complicated by emergency conditions) may often be appropriate, as long as the physician specifies the nature of those conditions. Although Medicare does not pay for these codes, some private payers might.