Home

  • Home
    • » e-Newsletters

Understand coding for anesthesia services provided outside of the OR

JustCoding News: Outpatient, June 30, 2010

Want to receive articles like this one in your inbox? Subscribe to JustCoding News: Outpatient!

by Lois Mazza, CPC, PCA

Typically, physicians and registered nurses who have completed specialized training administer anesthesia services to provide patients with an absence of sensation so that they can comfortably undergo certain procedures and services, such as surgeries.

But anesthesiologists also provide pain relieving services outside of the operating room. Consider the following examples.

Epidural blood patch

Anesthesiologists provide epidural blood patches to patients suffering from headaches following a lumbar puncture (i.e., spinal tap) to assess patients’ cerebrospinal fluid.

Following the lumbar puncture, patients may experience severe headaches if spinal fluid continues to leak out. This type of spinal fluid leak might also occur following epidural anesthesia. This is because a physician must make a puncture in the patient’s spine for this type of service.

To perform an epidural blood patch, a procedure commonly performed in the ED, the anesthesiologist injects a small amount of the patient’s own blood into the site of the leak. The clot that results forms a ‘patch’ that contains the cerebrospinal fluid leak.

Report CPT code 62273 for an epidural blood patch. Note that complete documentation must include the following in the patient’s record:

  • Chief complaint (i.e., reason for procedure [in this case, typically post lumbar–tap]) headache)
  • Details of procedure
  • Date and time of procedure
  • Anesthesiologist’s signature for the note

Endotracheal tube insertion

Endotracheal tube insertion refers to intubation of a patient, often done emergently, because the patient is in respiratory distress or otherwise in danger of imminent harm to themselves or others. This type of situation typically requires a method of artificial respiration.

The physician inserts a tube into the trachea to facilitate artificial respiration. To perform an endotracheal tube insertion, the anesthesiologist might use a tool called a laryngoscope to help view the area below the vocal cords. The physician may also use this instrument to hold the tongue out of the way so that he or she can safely introduce the ‘breathing’ tube into the trachea.

Report CPT code 31500 for an endotracheal tube insertion. Note that complete documentation must include the following in the patient’s record:

  • Chief complaint (usually the sudden onset of respiratory failure)
  • Details of the procedure
  • Date and time of procedure
  • Anesthesiologist’s signature for the note

Many facilities have teams of providers who respond to emergencies within the facility (e.g., respiratory failures). Typically, one member of the team takes notes regarding the event. Some providers might mistakenly assume these notes supply sufficient documentation for the services, but this is incorrect.

Each individual on the team who provides services (e.g., endotracheal intubation) must provide complete documentation to support any charge associated with the service(s) he or she provided.

Some carriers routinely deny endotracheal intubation services pending the provision of the associated note. Providers need to understand that all services personally provided and for which a charge will be submitted must personally complete documentation for such services in the patient’s record.

Placement of epidural catheter for pain relief

Anesthesiologists often place epidural catheters to help provide pain relief for postop patients and other patients experiencing certain types of pain. Note that you may not bill separately for an epidural catheter placed before or during a procedure that will provide the main method of anesthesia for a procedure.

For placement of epidural catheter, a physician places a thin tube into the epidural space in the spine; the exact location depends on the type of pain. The catheter then supplies the pain medication.

For placement of an epidural catheter, report CPT code 62318 for the cervical/thoracic region and CPT code 62319 for the lumbar/sacral region. Note that complete documentation must include the following in the patient’s record:

  • Chief complaint (usually the type of pain from which the patient needs relief)
  • Details of the procedure
  • Date and time of the procedure
  • Anesthesiologist’s signature for the note

Daily hospital management of postop pain

Patients who have had surgeries and other procedures often experience a certain amount of postop pain. Anesthesiologists and other department staff (e.g., physician’s assistant, nurse practitioner) provide postop pain management services. You may not separately bill for pain management services provided on the same day as surgery.

To charge for daily hospital management of postop pain, the anesthesiologist or department staff must examine the patient on a day other than when the surgery took place and include a note detailing those services in the patient’s record.

Report CPT code 01996 for daily hospital management of postop pain. Note that complete documentation must include the following in the patient’s record:

  • Site of postop pain
  • Patient’s status (e.g., stable, improving, or worsening)
  • Results of patient exam
  • Changes to plan of care or continue same plan of care
  • A note in the patient’s record stating that the attending physician also examined the patient in addition to other staff members (e.g., physician’s assistant, nurse practitioner) when you intend to report a charge under the attending physician

Some facilities use a template for the record that includes an area for both notes (i.e., the staff member’s note and the attending physician’s note) for the purpose of documenting both providers’ exams.

As you can see, anesthesiologists provide a wide range of services outside of the operating room setting. A review of coding practices for these services would be wise to ensure that documentation supports appropriate reporting.

Editor’s note: Mazza provides compliance audits as well as other auditing and educational services for Physician Chart Auditors in Hull, MA. E-mail your questions to Mazza at loisefit88@yahoo.com.



Want to receive articles like this one in your inbox? Subscribe to JustCoding News: Outpatient!

Most Popular