Coding for Anesthesia Services - American Association of Oral and ...

equiring the presence of an independent trainedobserver to assist in the monitoring of thepatient’s level of consciousness and physiologicalstatus; younger than 5 years of age, first 30minutes intra-service time99144 age 5 years or older, first 30 minutes intraservicetime+ 99145 each additional 15 minutes intra-servicetime (List separately in addition to code forprimary service); note that this is an add-oncode and must be used in conjunction with99143, 9914499148 Moderate sedation services (other than those servicesdescribed by codes 00100-01999), providedby a physician or qualified health care professionalother than the health care professionalperforming the diagnostic or therapeutic servicethat sedation supports; younger than 5 years ofage, first 30 minutes intra-service time99149 age 5 years or older, first 30 minutes intraservicetime+ 99150 each additional 15 minutes intra-servicetime (List separately in addition to code forprimary service); note that this is an add-oncode and must be used in conjunction with99148, 99149In CPT 2013 there are many codes that have a “bullseye”designation 8 in front of the code. These codes havemoderate (conscious) sedation by the surgeon included inthe RVUs for that code. None of these codes are currentlyutilized by the OMS.Deep Sedation / General AnesthesiaTo report general anesthesia/deep sedation providedby the surgeon performing the surgical procedure, it isnecessary to add modifier “-47” to the surgical procedurecode. Modifier “-47” is not used as a modifier for theCPT Anesthesia Codes (00100 - 00352 for head and neckprocedures) as these reflect anesthesia services providedby an individual other than the operating surgeon. (Note:The five digit modifier format was eliminated from CPTbeginning in 2003 making the previous 09947 obsolete).For example, closed reduction of a mandibular fractureperformed in the office under deep sedation / general anesthesiawould be reported as: 21451 for the procedure, with21451-47 as a separate line item for the anesthesia.Some insurance companies will permit surgeons to reporttheir anesthesia services by utilizing codes from theAnesthesia chapter of the CPT Manual. Such anesthesiaservices are reported by the use of the anesthesia five digitprocedure code plus the addition of a physical status modifier.CPT codes 00100 through 00352 are the anesthesiacodes for the head and neck region. Unless advised otherwiseby a carrier, these codes are intended to be reportedby a provider administering anesthesia for the operatingsurgeon, or overseeing a CRNA. In either case, these codesare not generally used to report operator administeredanesthesia.The surgeon may be able to bill for supply of the anestheticagent, as well as possibly for IV antibiotics, analgesicsand anti-inflammatory agents. The CPT supply code is99070. Some insurance companies may prefer the appropriateHCPCS Level II code representing the drugs administered(J codes).Anesthesia Relative ValuesAccording to the American Society of Anesthesiologists(ASA) Relative Value Guide, a “Basic Value” is assignedto the anesthetic management of most surgical procedures.This “Basic Value” includes “all usual anesthesia services,”except for the time actually spent in anesthesia careand any modifiers. “Usual anesthesia services” includesusual pre- and post-operative visits, administration of fluidsand/or blood products incident to anesthesia care, andthe interpretation of noninvasive monitoring (e.g., ECG,temperature, blood pressure, oximetry, capnography).When more than one surgical procedure is performedduring a single anesthetic, the “Basic Value” would be thatof the procedure which has the highest unit value.In addition to the ”Basic Value,” additional modifiers areused to accurately code and bill for services. These modifiersare primarily the “Modifying Units” [see below] and“Time Units.” Other modifiers exist, but have little or norelevance to practicing OMS’s.Physical Status ModifiersCoding PaperPhysical Status Modifiers should be appended to any CPTanesthesia chapter code. They are indicated with the initialPAGE 2 Coding for Anesthesia Services

letter “P” followed by a single digit from 1-6 as listedbelow:P1 -P2 -P3 -P4 -P5 -P6 -Normal healthy patient.Patient with mild systemic disease.Patient with severe systemic disease.Patient with severe systemic disease that is aconstant threat to life.Moribund patient, not expected to survive withoutthe operation.Declared brain-dead patient whose organs arebeing removed for donor purposes.These six levels are consistent with the ASA classificationof physical status and are added to the basic anesthesiacode in the same fashion as any CPT modifier. (Example:00190 - P2)Qualifying CircumstancesThough technically not modifiers, these codes serve todescribe anesthesia services under unusual or difficultcircumstances. Such unusual circumstances and servicesmay qualify for additional reimbursement when reportedin addition to the anesthesia code. These codes are notreported alone, but in addition to the qualifying anesthesiaprocedure or service. More than one CPT code may beused.+99100 Anesthesia for patient of extreme age, under oneyear or over 70.+99116 Anesthesia complicated by utilization of totalbody hypothermia.+99135 Anesthesia complicated by utilization of controlledhypotension.+99140 Anesthesia complicated by emergency conditions(specify).[Emergency is defined as existing when delay in treatmentwould lead to a significant increase in the threat to life orbody part.]Reporting TimeThe other factor to consider when billing for anesthesiaservices is time. Anesthesia time begins when the anesthesiaprovider begins to prepare the patient for inductionCoding Paperof anesthesia (typically when the intravenous access isestablished) and ends when he/she is no longer in personalattendance (i.e., when the patient is safely placed underpostoperative supervision). This is expressed as “TimeUnits.” The basic “Time Unit” is generally considered tobe 15 minutes. However, carriers may vary in how theydefine “Time Unit.” For example, 10 minutes could beconsidered the basic unit for some carriers. Be sure to verifywith specific carriers how they define such time units,and how they would like time reported. The HIPAA ElectronicTransaction Standard 5010 no longer accepts units,and requires the reporting of total anesthesia time. Thetotal time is coded on the claim form under the columnfor “Units.” The official instructions for completing theCMS 1500 are maintained by the National Uniform ClaimCommittee (NUCC). The most recent instructions provideguidance on reporting time above the date field in box 24of the claim form. For a visual example, visit nucc.org anddownload the most current instructions.WHAT ABOUT MEDICARE?Under Medicare, deep sedation/general anesthesia iscovered only for Medicare-covered procedures, and only ifadministered by another doctor or nurse anesthetist underthe supervision of another doctor. Medicare presentlybundles the payment for deep sedation/general anesthesiaadministered by or under the supervision of the operatingsurgeon.Thus, general anesthesia/deep sedation by surgeon isnon-covered and non-billable for Medicare coveredservices. If, however, anesthesia is billed by a separate individualfor a Medicare-covered service, time should be reportedin accordance with policies of your local MedicareAdministrative Contractor and the current instructions setforth by the National Uniform Claim Committee availableat http://www.nucc.org.Moderate sedation by the surgeon, on the other hand, iscarrier priced. This allows individual Medicare Part Bcarriers discretion regarding approval and payment rates.PAGE 3 Coding for Anesthesia Services

DENTAL CODING FOR ANESTHESIAUnder both medical (CPT) and dental (CDT) coding,the use of local anesthesia is considered an inherentcomponent of any surgical procedure, and is not billableseparately.Significant differences exist between anesthesia billing underCPT and CDT. Notable among these are the absenceof modifiers and the “Time Unit” concept. CDT does notdistinguish between operator administered anesthesia andthat provided by another practitioner. The concepts offacility, supplies and materials are also inherently differentin dental and medical billing. It is important to keep thesedifferences in mind when coding.When submitting anesthesia charges to a dental insurancecarrier, the following CDT 2013 codes should be used:D9220 deep sedation/general anesthesia - first 30minutesD9221D9230D9241D9242D9248deep sedation/general anesthesia - eachadditional 15 minutesanalgesia, anxiolysis, inhalation of nitrous oxideintravenous conscious sedation/analgesia – first30 minutesintravenous conscious sedation/analgesia – eachadditional 15 minutesnon-intravenous conscious sedationDEFINING START AND STOP TIMEAs noted, anesthesia start time commences when the anesthesiaprovider initiates the appropriate anesthesia protocoland remains in continuous attendance of the patient. Anesthesiatime ends when the anesthesia provider can safelyleave the patient under postoperative supervision. Thus,anesthesia services and time are considered completedwhen the patient may be safely left under the observationof a trained anesthesia assistant, and the doctor may safelyleave the room to attend to other duties.Additional CDT anesthesia codes exist, but do not applyto anesthesia utilized in conjunction with a procedure.These codes are:D9210D9211D9212local anesthesia not in conjunction with operativeor surgical proceduresregional block anesthesiatrigeminal division block anesthesiaD9215 local anesthesia in conjunction with operative orsurgical proceduresCoding PaperUSING DENTAL CODES ON MEDICAL CLAIMSIn general, CPT codes are not used on ADA forms andCDT codes are not used on CMS 1500 (Medical) forms.However, some medical carriers may direct that you useCDT codes on a CMS 1500 form for “dental” procedureswhich do not have an applicable CPT code (e.g. thirdmolars). In those situations, they may also request use ofCDT anesthesia codes.The presence of an anesthesia code, or any procedure code,does not guarantee payment for these services. It is crucialfor the OMS practitioner and his/her staff to understandthe intricacies of reimbursement for anesthesia services byeach carrier, managed care organization and Medicare.Note: This paper should not be used as the sole reference in coding.Both diagnosis and treatment codes change frequently, and insurancecarriers may differ in their interpretations of the codes.Coding and billing decisions are personal choices to be made by individualoral and maxillofacial surgeons exercising their own professionaljudgment in each situation. The information provided to you inthis paper is intended for educational purposes only. In no event shallAAOMS be liable for any decision made or action taken or not takenby you or anyone else in reliance on the information contained in thisarticle. For practice, financial, accounting, legal or other professionaladvice, you need to consult your own professional advisers.This is one in a series of AAOMS papers designed to provideinformation on coding claims for oral and maxillofacial surgery(OMS). This paper discusses coding for anesthesia. This paperis to aid the oral and maxillofacial surgeon with proper diagnosis(ICD-9-CM) and treatment (CPT/CDT) coding for anesthesia.When indicated, you will be referred to the appropriate area ofthe coding books where the principles of coding illustrated in thispaper may be applied.Proper coding provides a uniform language to describe medical,surgical, and dental services. Diagnostic and procedure codesare continually updated or revised. The AAOMS Committee onHealth Care and Advocacy has developed these coding guidelinesin order to assist the membership to use the coding systemseffectively and efficiently.© 2013 American Association of Oral and Maxillofacial Surgeons.No portion of this publication may be used or reproduced withoutthe express written consent of the American Association of Oraland Maxillofacial Surgeons.Revised March 2013PAGE 4 Coding for Anesthesia Services