Pain providers may see more denials this year. SI injections (27096), epidurals (62310-62319) paravertebral facet injections (64490-64495) and greater occipital nerve blocks (64405) are now designated as “Anesthesia Care Not typically required” in the American Society of Anesthesiologist (ASA) 2011 Crosswalk.

Many insurance carriers use the ASA crosswalk as their guide for linking procedures together. When the carrier sees the new designation for the anesthesia services, they may issue a denial. To achieve payment, you will need to prove services were medically necessary due to an underlying condition requiring the patient to be monitored throughout the service or a condition that prevented the patient from holding still or lying prone for the duration of the procedure.

Pain and anesthesia practices should look at local medical policies to determine if carriers deem the use of a second physician necessary to provide anesthesia during interventional pain management procedures. Just because you may not find a LCD (local carrier determination), doesn’t mean medical necessity isn’t an issue. LCD’s are often updated long after the fact and medical necessity is always the underlying issue for any patient, anytime and for every procedure.

One Medicare carrier (Care First) has issued this policy for monitored anesthesia care codes (01991-01992) during interventional pain management services.

“The patient’s medical condition or nature of the procedure requires the presence of a second physician represented by an anesthesiologist or qualified anesthesia provider to administer the sedation if utilized to manage the airway & vital signs, and to continually assess the patient for clinical problems and treat appropriately to ensure patient safety and comfort.”

“The presence of an underlying condition alone or a stable treatable condition is not sufficient evidence that monitored anesthesia care is medically reasonable and necessary.”

According to First Coast, some conditions that demonstrate medical necessity:

  • Co-morbidities such as pulmonary disease, cardiac disease, morbid obesity, severe sleep apnea
  • Inability to follow simple commands caused by developmental delay or dementia
  • Spasticity disorders that would make it difficult for the patient to lie still
  • Severe anxiety immediately prior to the procedure which may affect patient safety and comfort
  • The patient is a Medicare –eligible pediatric patient

A diagnosis alone will not prove medical necessity. The patient’s condition must be significant enough to impact the need to provide MAC (such as the patient being on medication or symptomatic, etc.). The presence of a stable, treated condition is not generally sufficient medical justification for MAC, First Coast writes. They go on to give an example:

“An otherwise healthy patient who suffers from senile dementia with delusional features (290.20) is scheduled for a single-level lumbar paravertebral face injection (64493). However, the patient is able to understand and follow instructions, holds still for the duration of the procedure and shows no signs or symptoms of unusual anxiety before the procedure. The carrier would issue a medical necessity denial for anesthesiologist’s services.

When you are scheduling the case, indicate the medical necessity to your scheduler. It may assist in the precertification process and potentially help with appealing the denial, if necessary.

read more

Choosing The Correct code Nosebleeds

On March 8th, 2011, posted in: Medical Coding, Tips by

When a patient presents with an active nosebleed, choosing the wrong code could lose you as much as $100.00 in reimbursement. Let’s look at an example:

An established patient presents after sustaining injuries playing soccer. A ball hits the patient’s face, which makes the nose bleed and gives him a black eye. You document a detailed history, exam and decision making is of moderate complexity. The patient is also complaining of a headache. You can’t stop the nose bleed with ice or pressure, so you perform extensive cautery using silver nitrate sticks on both nostrils, and repeat the procedure again. You order an x-ray to ensure the nose is not broken, the results come back negative. How should you code this?

  • 99214 – detail history, exam and moderate decision making – diagnosis 784.0 – headache/facial pain – with modifier ‘25’
  • 30903 ‘50’ (because you treated both nostrils) – control nasal hemorrhage, anterior complex, extensive cautery and/or packing – diagnosis 784.7 – epistaxis, E917.0 – striking against or accidentally by object or person in sports without subsequent fall and E007.5 – activity involving other sports and athletics played as a team or group soccer

Because you documentation is clearly defined on how your treated the nosebleed, using several attempts, reporting 30903 instead of 30901 (limited cautery and/or packing- defined as applied continuous pressure, inserted pledgets soaked with anesthetic-vasoconstrictor; administered nasal spray; chemical cautery, 1x only) you reimbursement would yield amount $100.00 more.

Make sure you choose the code that defines the services you performed.  Remember if you stop the nose bleed simply by using ice, you would only report the E/M code.

read more