Anesthesia and Surgical Sections

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Anesthesia and Surgical Sections

• CPT Coding

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Anesthesia

• The partial or complete absence of normal
  sensation.
• Administered by Anesthesiologist, Nurse
  anesthetist, or physician
• Different types categorized by their effect on
  the body (1) topical, (2) local (3) regional, (4)
  general.

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Regional and General

• The only two types that can be billed separate
  from the actual procedure sort of as a stand
  alone procedure.

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Sections

• Divided into sections based on anatomic sites.
• Only exceptions are Radiological procedures, Burn
  Excisions or Debridement and Other procedures.
• Radiological procedures sometimes require
  anesthesia. The Burn section is based on if
  BSA involved .

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Questions to ask yourself

• Where
• What
• Who

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The Where, What and Who of It.

• Where was the surgery performed (anatomic site)
• What type of anesthesia was given (regional,
  general)
• Who provided the anesthesia (NA, MD, etc.)

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No Matter Who

• The anesthesiologist must determine the patients
  physical status and document the information.
• YOU must take that information and select what is
  called a Physical Status Modifier (P1-P6)
• Qualifying circumstance Age, Healthmore money

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Time

• Anesthesia time is calculated based on how long
  the anesthesia was administered to the client.
• Hours and minutes are recorded in the OR
  recordBilled in 15 minute units.

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Surgery Section
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Outside In

• This is the LARGEST section of the CPT book.
• Has 16 subsections divided according to body
  systems Respiratory, Musculoskeletal,
  Integumentary, etc.
• Then this is again subdivided based on anatomic
  site Head, neck back, etc.

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Then again!

• Subdivided again into type of procedure
  excision, repair, destruction, graft.

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How to Code Effectively

• Analyze a procedure description and identify
  terms that will direct you to the correct code.
• Find the procedure in the INDEX first.
• Once you have found the code range go to the
  correct section in the front of the book and read
  ALL of the descriptions before you pick a code.

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Coding Effectively Continued

• You must understand how to read a description.
• There are two types of codes (found after you
  find the code range in the index and turn to the
  front of the book)

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Two Types of Code

• Stand Alone Has a complete procedure description
• Indented Code You have to first read the portion
  of the stand alone code BEFORE the semicolon ()
  and then move down to the indented code.

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Example

• 6-3

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The Operative Report

• Get a copy of the report from the hospital
• Get a ruler and scan the document line by line
  highlighting words that may give you a clue to
  the procedure.
• Do NOT code a procedure based on what is given in
  the heading.

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Bundled vs. Unbundled

• BundledBlue Plate Special
• Unbundled A La Carte
• See overhead

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Complex Procedures

• If the code is just not sufficientadd an
  addendum
• Insurance companies do not like addendums
• Can use modifier 51 to indicate multiple
  procedures
• Can use the words extensive complications

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GOLDEN RULE

• If it isnt documented it wasnt done.
• Never code a procedure just based on what the MD
  tells you.get him to give you an addendum

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The STAR

• () Indicates minor surgical procedures

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What does that mean?

• The service is for the surgical procedure ONLY.
• All post-op care is an add on.
• .Any complications are an add on.
• Preop and follow up Examples pg. 141

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Decision for Surgery

• What if we decide to do surgery during an office
  visit? Can I charge for an EM service?
• 99025New patient only. Starred proceduremajor
  serviceprocedure same day.
• -57new OR established patient. Unstarred 90 day
  global --within 24 hours.

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Decision for Surgery

• -25New OR established.
• Starred/Unstarred minor procedure (0-10 day
  global)
• Significant, separately identifiable E/M service.
• Procedure same day.

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Questions to ask yourself--

• Is the patient new or established?
• Is the code starred or unstarred?
• Is the E/M service significant and separate?
• What is the time lapse from when you decide to do
  surgery to the actual procedure?

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Additional Notes

• 99025Found in the Medicine section. Used
  instead of an E/M code for new patientstarred
  procedure which is the major service at the
  visit.
• -57Used only to report an E/M service that
  resulted in decision to perform surgery within 24
  hours of the encounter (90 day follow-up)

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Additional Notes

• -25modifier Significantly separate E/M service
  by same MD on same day.

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The Package

• If there is no () it is a package deal.
• A surgical package is commonly found in the
  surgery section of the CPT.
• It is a procedure NOT followed by a .
• One fee covers all accompanying services.
• Also known as a Global Package

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What is included?

• The operation
• Anesthesia
• One related E/M code
• Postoperative care (uncomplicated)

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Medicare Global Package

• Preop E/M services
• Intraoperative services
• Postoperative visits (0-90 days)
• Complications that do no require an additional
  trip to the OR
• Anesthesia
• Supplies for the procedure

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Items not covered

• Initial consultation
• Diagnostic tests
• Treatment to stabilize a condition
• Postoperative visits unrelated to the dx.
• Related procedures for postop complications
  requiring another trip to OR
• Immunosuppressive therapy for transplant

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Follow up visits

• Minor surgeries 0-10 days
• Major surgeries 45-90 days
• For providing care within the global
  period.99024 in the Medicine section.

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Multiple Procedures

• Multiple procedure modifier (-51)

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Money

• Payment for the primary code is 100 of the
  allowable
• Second code is 50 of the allowable
• Third code is 25 of the allowable and the rest
  10.
• It is important to document the most expensive
  first.

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Medicare

• Will pay 50 of the allowable for 2-5 secondary
  procedures and does not require modifier 51.
• Always bill for the full amount and let the
  carrier figure out the percentages.

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Add on codes

• ()
• Represents an additional procedure done with the
  primary.
• Cannot be billed without the primary (parent)
  code.
• See 6-6

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Bilateral Procedures

• -50
• Does the code description define the procedure as
  bilateral? If so, you dont need the modifier.
• If not, you need the modifier.
• Medicare pays 150 of the entire bilateral
  procedure.

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Assistant at Surgery

• -80
• Use the same procedure code that the primary
  surgeon used.
• The assistant surgeon is typically paid 16-30 of
  the fee allowed for the primary surgeon.

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Integumentary System

• First subsection
• Malignant vs. benign
• Lesion any discontinuity of the skin
• When coding a lesion anatomic site, size in cm.
  , number removed, process used to remove, and
  morphology.

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Repair of Laceration

• Simple, intermediate, complex
• Multiple lacerations repaired with the same
  technique in the same anatomic category---add up
  the length and report one code. See 6-10.

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Surgical Supplies

• To charge or not to charge
• Was the procedure or not?
• Supplies that are above and beyond can be found
  in either the Medicine Section of the CPT or the
  HCPCS book.

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Musculoskeletal System

• Arranged by anatomic site.
• Typically head to toe concluding with the feet.
• Subcategories see pg. 147

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Fractures

• Either closed or open.
• Treatment is either open, closed or percutaneous.
• Manipulation is manual stretching or traction to
  realign a boneaka reduction.
• Fixation refers to hardware used to keep a bone
  in place. It can be internal or external.

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Respiratory System

• Endoscopy
• Can include a biopsy
• The further the scope is passed down, the more
  complex the procedure.
• Endoscopies are named for the area of the body
  being visualized.
• Bronchoscopy

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Cardiovascular system

• Includes procedures of the heart and blood
  vessels.
• Includes pacemaker implantation, CABG and
  vascular studies.

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Digestive System

• Includes accessory organs like liver, pancreas
  and gallbladder.
• Also includes endoscopic procedures like
  sigmoidoscopy, colonoscopy, proctosigmoidoscopy.

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Urinary system

• Endoscopies
• Ureteral
• Cystoscopy
• Urethroscopy

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Male and Female Reproductive

• Anatomic categories
• Lesions found on organs in the MRS should be
  coded in this section and not in the
  Integumentary system.
• FRSmaternity care, delivery, some ID,
  abortions, deliveries.

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Radiology Section

• Includes nuclear medicine and dx. Ultrasound
• Professional and Technical Components
• Professional (MD)..Technical (facility and
  operator)
• Professional refers to the part the MD
  doesinterpreting the xray or EKG.

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Technical

• The technical component refers to the use of the
  equipment and the operator that does the test.
• If the MD does both, you do not need to modify
  the code.
• Use modifier 26 when the MD completes only the
  professional component
• Use TC when billing only for the technical
  component

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Example 6-18

• Also note that Medicare does not cover the TC of
  any service rendered in a hospital or OP setting.

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Combination Coding

• See a lot in Radiology
• Injection of contrast material, placement of
  catheters, placement of guidewires, placement of
  stents.
• See 6-19

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Pathology and Lab Section
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Format

• Codes are listed in subsections according to type
  of test.chemistry, hematology, serology.
• Pay close attention to descriptions. Many tests
  can be performed using urine OR blood.
• Tests can be done manually or can be
  automatedthis is in the description..

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Test Panels

• A panel is basically one blood test that checks a
  number of blood components.
• For instance A basic metabolic panel vs. a
  comprehensive metabolic panel
• Example

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Test Panel Guidelines

• In order to use the code for a Basic Metabolic or
  Comprehensive Metabolic panelEVERY one of the
  tests must be included.
• Some insurance companies require that a dx. Be
  present for EACH of the components.

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Qualitative vs. Quantitative

• Qualitative test determines the presence of an
  agent in the body.
• Quantitative measures how much of it is present.
  (quantity)
• Example A drug assay will screen for the
  presence of cocaine. You will have to have a
  quantitative test to say how much cocaine is in
  the system.

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Surgical Pathology

• Arranged according to levels
• Level I means that the pathologist looked at
  the specimen with the naked eye(gross
  examination)
• Level II means he looked at it with the naked eye
  and microscopically

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Example

• An ovary is removed and sent to the pathologist.
  A level I exam would indicate the size, shape,
  color and overall appearance of the ovary. A
  level II exam would include those items PLUS
  information on perhaps the interior, any abnormal
  cells (microscope).

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Medicine

• This section crosses over with the CPT.
• Diagnostic and therapeutic codes that are not
  surgically invasive (Surgery section)

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Drugs and Injections

• Five codes in this section
• (1) therapeutic, (2) prophylactic (3) diagnostic
  injections.
• The insurance company will want to know what was
  injected. This can be accomplished in 3
  different ways

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3 Ways

• Block 19 of the CMS 1500 list the name, amount,
  strength
• 2a NDC code
• 3A HCPCS code

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Coding Terminology

• Bundled Code
• Unbundling
• Downcoding
• Upcoding
• Code Edits

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Illegal or Unethical Coding

• Page 158

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Golden Rule

• To be sure a surgical package is delivered
  correctly, check to see if it is bundled.