Bundled Services With Anesthesia
When performing an anesthetic, there are many clinical services that are provided by anesthesia practitioners. This article is intended to discuss the procedures considered inclusive of the standard anesthesia base unit value, along with items that can be billed under certain circumstances.
Medicare’s National Correct Coding Initiative
Although individual payers have unique anesthesia coverage criteria, Medicare’s National Correct Coding Initiative is the best place to start.
The NCCI was developed decades ago to help identify bundled codes through claims automation, as well as to provide guidance to providers on billing and documentation matters. Many private payers follow similar guidelines.
NCCI Bundled Anesthesia Services
- Transporting, positioning, prepping, draping of the patient for satisfactory anesthesia induction/surgical procedures.
(Exception – transporting from ICU to OR, or vice-versa)
- Placement of external devices including, but not limited to, those for cardiac monitoring, oximetry, capnography, temperature monitoring, EEG, CNS evoked responses, and Doppler flow. (Includes BIS monitoring, excludes invasive monitoring lines)
- Placement of peripheral intravenous lines for fluid and medication administration.
(Exception – difficult IV starts for non-anesthesia patients)
- Placement of airway (e.g., endotracheal tube, orotracheal tube)
- Laryngoscopy (direct or endoscopic) for placement of airway. (Includes fiberoptic intubation)
- Placement of nasogastric or orogastric tube.
- Intra-operative interpretation of monitored functions.
(e.g., blood pressure, heart rate, respirations, oximetry, capnography, temperature, EEG, BSER, Doppler flow, CNS pressure)
- Interpretation of laboratory determinations
(e.g., arterial blood gases such as pH, pO2, pCO2, bicarbonate, CBC, blood chemistries, lactate) by the anesthesiologist/CRNA.
- Nerve stimulation for determination of level of paralysis or localization of nerve(s).
(Codes for EMG services are for diagnostic purposes for nerve dysfunction. To report these codes a complete diagnostic report must be present in the medical record.)
- Insertion of urinary bladder catheter.
- Blood sample procurement through existing lines or requiring venipuncture or arterial puncture.
(Includes Cell Saver procedure)
Other Interesting Notes from the NCCI
- CPT codes 99151-99157 describe moderate (conscious) sedation services.
(These codes would never be used by an anesthesia provider. Time-based MAC anesthesia would be billed instead.)
- In counting anesthesia time, the anesthesia practitioner can add blocks of time around an interruption in anesthesia time, as long as the anesthesia practitioner is furnishing continuous anesthesia care within the time periods around the interruption.
(Requires charting of multiple start/stop times)
- If a surgery is canceled, subsequent to the preoperative evaluation, payment may be allowed to the anesthesiologist for an E&M (visit) service and the appropriate E&M code may be reported.
(Requires submission of pre-anesthesia assessment)
- If permitted by state law, anesthesia practitioners may separately report significant, separately identifiable postoperative management services after the anesthesia service time ends.
These services include, but are not limited to, postoperative pain management and ventilator management unrelated to the anesthesia procedure.
(Ventilator management cannot be just providing the initial settings)
- Management of epidural or subarachnoid drug administration (CPT code 01996) is separately payable on dates of service subsequent to surgery, but not on the date of surgery.
(Can be billed each calendar day as medically necessary, including the day of discontinuing the catheter. Documentation must show that the provider physically saw the patient.)
- Transesophageal echocardiography – When performed for diagnostic purposes with documentation including a formal report, this service may be considered a significant, separately identifiable, and separately reportable service.
(Probe placement and/or monitoring with no formal report generated by a physician is not separately billable to Medicare)
- Postoperative pain management services are generally provided by the surgeon who is reimbursed under a global payment policy related to the procedure and shall not be reported by the anesthesia practitioner unless separate, medically necessary services are required that cannot be rendered by the surgeon.
The surgeon is responsible for documenting in the medical record the reason that care is being referred to the anesthesia practitioner.
(Surgical Order Recommended)
- A peripheral nerve block injection for postoperative pain management may be reported separately with an anesthesia code only if the mode of intraoperative anesthesia is general anesthesia, subarachnoid injection, or epidural injection, and the adequacy of the intraoperative anesthesia is not dependent on the peripheral nerve block injection.
These blocks may be administered preoperatively, intraoperatively, or postoperatively.
(Make sure that your providers are not documenting “MAC” for Propofol/TIVA cases, which are considered as “General”)
MSN Healthcare Solutions
Hal Nelson, CANPC
has 30 years experience on both the payer and RCM side, with a focus in Anesthesia. He formerly worked as a senior claims approver at United Healthcare, as well as a compliance officer for multiple national billing companies. He has also taught the CPC coding curriculum collegiately in Atlanta. His broad based experience ensures that MSN clients will have a resource for documentation and billing issues. His past speaking engagements include ASA, MGMA, Dartmouth, and Johns Hopkins.
This educational guide was prepared as a tool to provide education for documentation and coding. It is not intended to affect clinical treatment patterns. The material provided is for informational purposes only. Efforts have been made to ensure the information within this document was accurate on the date of distribution. Reimbursement policies vary from insurer to insurer and the policies of the same payer may vary within different U.S. regions. All policies should be verified to ensure compliance. CPT® codes, descriptions and other data are copyright of the American Medical Association (or such other date of publication of CPT®).All Rights Reserved. CPT® is a registered trademark of the American Medical Association. Proprietary and confidential document. All rights reserved. No part of this document may be reproduced or used in any manner without the written permission of MSN Healthcare Solutions, LLC.