Many anesthesia providers tend to assume that it is the job and responsibility of the billing staff to ensure that all claims are correct and completely supported by the anesthesia record. This is why it is so important that all providers understand and appreciate the subtlety and nuances of anesthesia billing. Optimal billing is always a collaborative exercise involving the provider and the biller.
Noting the Nuances
Surgical activity in a typical hospital can easily involve 2,500 surgical CPT codes, most of which have a one-to-one relationship with a designated ASA code. It is the ASA code that determines the basic value for the case. The problem is that there are about 80 CPT codes that can be matched to multiple ASA codes. This is where the anesthesia documentation makes a difference. For these cases, three factors are critical:
- What was the primary mode of anesthesia? The coder needs to know if the case was performed under general anesthesia, regional or monitored anesthesia care (MAC).
- What was the location of the surgical field? If the case was abdominal, did the procedure (not the incision) involve the upper abdomen (above the umbilicus) or the lower abdomen (below the umbilicus)?
- Were there any special anesthesia considerations, such as the need for one-lung anesthesia?
All of these considerations could impact the number of units billed for the case. Consider anesthesia for a shoulder or knee arthroscopy. If the procedure description includes details of the surgical procedure performed, the case will have a base value of 4 units; but if such detail is missing, the case would only have a base value of 3 units.
Cases in Point
The objective of all anesthesia practices today is to capture all billable services in an appropriate and compliant manner. This means providers must remember to include whatever details could impact the claim that is ultimately submitted to insurance. Consider anesthesia for a spinal fusion. A typical code we see is code 00630, anesthesia for procedures in lumbar region; not otherwise specified. This code is used to indicate a spinal fusion in the lumbar region and is valued at 8 units in the ASA’s Relative Value Guide (RVG). However, the code used to reflect the use of instrumentation or multiple vertebral segments (at least two interspaces), 00670, is assigned 13 units in the RVG.
In order to obtain the additional five units associated with code 00670, the provider must document the instrumentation, assuming it was utilized in the case, or denote that the procedure involved a minimum of three vertebral bodies with two associated interspaces. A review of claims for four large Coronis Health clients indicated that, in 4% of the cases, this critical information was missing and needed to be retrieved from the operative report.
One of the most common coding issues involves abdominal procedures. Upper abdominal procedures are worth seven base value units, while those limited to the lower abdomen are worth six units. The point of demarcation is the umbilicus. A recent review of 187 laparoscopies performed last year by the four Coronis Health clients showed 82% of such cases were coded as involving either the upper or lower abdomen. The remaining 18% needed to be retrieved from the operative report.
These are just a couple of examples of the idiosyncrasies of anesthesia coding, but they highlight the value of ongoing provider education.