12/29/15 – Documentation policies for routine cesarean follow-ups by anesthesiologists


Question: Is it appropriate to bill a post-operative visit when the anesthesiologist checks on the patient the day after a cesarean delivery (01961)?

Answer: A follow-up visit is permissible when there’s a documented complication (e.g. itching or pain). Report the subsequent care code when the patient does not have a catheter, and the visit meets the requirements for an E/M visit. Use 01996 when a catheter is still in place.



Documentation: Include All These Details for Cancelled Anesthesia

Published on December 22, 2015 by The AAPC

Remember, timing is everything.

As an anesthesia coder, you know you have special considerations when filing a claim for a procedure that was canceled before its completion. Here’s exactly what your providers need to be documenting for reimbursement success.

Situation 1: Cancellation Between Evaluation and Induction

Sometimes a physician – either the surgeon or anesthesiologist – decides to cancel a procedure prior to anesthesia induction because of something related to the patient’s health status (such as high blood pressure) or other circumstances (such as equipment failure).

If the anesthesia provider has completed the preoperative evaluation but has not induced the patient, he might still get paid for his time. The way you handle this depends on the situation and the insurer’s guidelines.

  • If the case is rescheduled for two or more weeks later, you may be able to bill for the pre-op care as a separate service. “Many of the policies I see allow for separate billing if the surgery is scheduled more than 30 days after the cancellation,” says Kelly D. Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Fla. “However, the Conditions of Participation require the pre-anesthesia evaluation within 48 hours of surgery.”
  • If the payer accepts consultation codes, you can report the service that way (99241- 99245 for office/outpatient or 99251-99255 for inpatient). However, your best tactic is to check the payer guidelines and any state-specific guidelines to ensure you’re filing correctly. For example, Dennis says that Blue Cross/Blue Shield of Alabama allows an E/M code, but Harvard Pilgrim allows a consultation code.
  • If the case will be attempted again in a week or less, your provider probably will complete a brief pre-op exam instead of another full evaluation. If so, the original full exam will count toward the anesthesia service and you won’t bill for both encounters.

Caution: In the past, you might have reported the cancellation with an E/M code and modifier 53 (Discontinued procedure) but that’s no longer correct. Current CPT® guidelines state that you don’t use modifier 53 “to report the elective cancellation of a procedure prior to a patient’s anesthesia induction and/or surgical preparation in the operating suite.”

Be sure your provider includes the following documentation when a case is cancelled before induction:

  1. Reason for termination
  2. Services actually performed
  3. Time spent giving pre-op care.

Situation 2: Cancellation After Induction

Under certain circumstances, a physician may terminate a surgical or diagnostic procedure due to extenuating circumstances or a situation that threatens the well-being of the patient (meaning continuing the procedure would put the patient at risk). For example, the anesthesiologist might see that the patient’s blood pressure has changed enough to merit stopping the case.

The following documentation must be included when a case is cancelled after induction:

  1. Reason for termination
  2. Service actually performed
  3. Time spent giving pre-op, operative and post-op care
  4. CPT® code for the procedure.

You have two coding options in this scenario. Some payers allow you to report the actual code in these situations (based on the planned procedure); others prefer 01999 (Unlisted anesthesia procedure[s]). From an anesthesia standpoint, the preferable way is to report the actual anesthesia code since it has an associated base value. Code 01999 is reimbursed based on individual consideration but must be reported if required by the carrier.

Tip: Also attach a brief note to the claim that points out the percentage of the procedure that was finished and why the procedure had to be stopped. For example, a comment such as, “30% of the procedure was completed. It was terminated as the patient had cardiac arrest” gives the insurer a clear understanding of the situation.



New coding guidance: New paravertebral blocks — “Whatever you do, don’t report imaging separately”

Published by Anesthesia & Pain Coder’s Pink Sheet, by Julia Kyles, CPC-A, December 17, 2015


Anesthesia providers will receive payment for two more post-op pain services in 2016. But the codes come with a list of restrictions, including an absolute bar on fluoroscopic or ultrasound guidance, according to Marc Leib, M.D., J.D., American Society of Anesthesia, AMA/Specialty Society Relative Value Scale Update Committee Advisor.


Leib addressed the new codes: 64461 (Paravertebral block [paraspinous block] thoracic; single injection site [includes imaging guidance when performed]), add-on code 64462 (…; second and any additional site[s] [includes imaging guidance when performed][List separately in addition to code for primary procedure]) and 64463 (…; continuous infusion by catheter [includes imaging guidance when performed]) during the 2016 AMA/RBRVS Symposium in Chicago.


“With these new codes, there are a number of things you cannot do,” Lieb said. A note in the 2016 CPT manual states you cannot report the blocks with the following codes: 62310, 62318, 64420, 64421, 64479, 64480, 64490-64492, 76942 and 77002-77003. However, Lieb stated the blocks should not be reported with any spinal injections, somatic blocks or other nerve blocks. Watch your payers and Medicare carrier for more guidance on these codes.


Report add-on code 64462 “when you do a second injection on same side or contralateral side,” Lieb said. Catheter code 64463 is appropriate when “continuous infusion is performed through a percutaneous indwelling catheter that is left in place during the course of the infusion. The infusion may be either repeated intermittent boluses through the catheter or an uninterrupted infusion by a pump at a set infusion rate,” Lieb said.


All three codes have a medically unlikely edit (MUE) of 1. The MUE adjudication indicator of ‘2’ means there is no way to appeal a denial for additional units of service.


Differentiate between blocks and transforaminals

In response to a question about the difference between transforaminal epidural injections (64479-64484) and paravertebral blocks, Lieb explained that transforaminals include imaging from CT or fluoroscopy; the blocks include any imaging, including ultrasound.


Coders who need help selecting a code should look at the method and the amount of medicine used during the procedure. For transforaminals, “the injection volume is less and is intended to block a single nerve within the epidural space.” The injection for a paravertebral block “is greater and is intended to block several nerves at the point of exit from the spinal column,” Lieb explained.


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