Reprinted with Permission, Medi-Corp, Inc.
By Marcy Garuccio, ACS-AN, CANPC, CPMA, CPC
Specificity matters when coding anesthesia services. A surgeon, facility or physician requesting anesthesia services is not enough to guarantee that these anesthesia services will be deemed medically necessary and reimbursed by insurance carriers. Many carrier guidelines require medical justification for surgical services and, in conjunction, the anesthesia service will follow suit.
Often, surgeons and facilities do not include anesthesia services in the precertification and authorization process and sometimes it is not needed, but often times it helps. This process lets the payers know in advance that surgical as well as anesthesia services have been requested and gives the payer an opportunity to let the surgeon know what will and will not be covered, so very important with the “No Surprise Act” in play. It could be due to a service they feel does not qualify as medically necessary; it may also be an exclusion in a patient’s coverage.
What can anesthesia providers do to assure the service is medically necessary?
Document specifically the reason for the service. Paint a picture. Often there are clinical reasons; co-morbidities and systemic illness that require the presence and service of the anesthesia care team.
An example I can easily give is an anesthetic given due to a patient with extreme anxiety, one that requires medical treatment by a PCP provider. As coders we can only code what is documented, and if all we see is anxiety, we document as directed by ICD-10-CM guidelines: anxiety, unspecified (F41.9). In my review of a denial due to a payer policy, I found several codes for anxiety that would meet this payer’s medical necessity requirements: F41.1, generalized anxiety disorder, F43.22 adjustment disorder with anxiety, F43.23 adjustment disorder with mixed anxiety and depressed moods. Many insurance carriers will not give us a pass on unspecified codes. They want more specific detail.
I am not suggesting that the coder guess or assume the more specific details. I am recommending that they query the provider to seek the more specific reasons for these types of clinical issues and avoid reporting an unspecified diagnosis if appropriate.
My feeling is that if a provider is servicing a patient, they should not be denied for that service for poor documentation when clinically quite often the required service would be justified if the documentation were more accurate and complete.
Another example I can give is obesity, unspecified (E66.9). In this payer policy it is not listed, but morbid (severe) obesity due to excess calories (E66.01) and morbid (severe) obesity with alveolar hypoventilation are listed.
Again, we as coders cannot assume these more detailed codes when they are not assigned and documented by a provider (See: ICD-10-CM Section I, B.14 “Documentation by Clinicians other than the Patient’s Provider”).
A practice may implement policies like a standing order. An example would be that it is acceptable for a coder to assign morbid obesity due to excess calories (E66.01) for an adult with a BMI of 40 and over. Coders can adhere to internal policies that are signed off by the authorized physician. These policies would be included with any request to audit coding, supporting where the coder got permission for those code assignments.
We realize physicians and clinicians are busy with great patient care. It is our goal as coders to streamline the payment process compliantly in connection with those services. Detailed documentation can achieve that goal and result in the win/win result. Faster turnaround and less ‘send-backs’ for missing or unclear documentation.
The examples given within this article are not from policies that every reader can utilize. It is important for each practice to investigate the payer policies applicable to their contracts and areas of service. This article should not be utilized as an instructional tool, only as an educational assistant to support the necessity of specific documentation requirements and their merits.
CPT: Essentials of Anesthesiology Coding and Billing
Coding of anesthesiology services is complex and requires mastery of both CPT and the ASA coding systems in order to ensure accurate, complete, and defensible code selection. CPT: Essentials for Anesthesiology Coding and Billing by Marcy Garuccio, offers a unique training perspective by bridging the gap between reporting and reimbursement for commonly occurring anesthesia services. Learn more here.