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March 14, 2011

Some anesthesia groups are seeing a growing number of denials of claims for evaluation and management (E/M) services provided in the postoperative period. Specifically, some of these denials are based on a new policy that California’s Anthem Blue Cross implemented effective November 21, 2010, disallowing “postoperative E/M visits reported within a 10 day aftercare period for anesthesia services.” This policy appears much more restrictive than that of other payers.  In effect, it would create a 10-day global period for anesthesia services, although Medicare and other payers do not recognize any such thing.

According to the guidelines published in the American Society of Anesthesiologists’ 2011 Relative Value Guide, “The usual anesthesia services included in the Base Value include the usual pre-operative and post-operative visits.” What are “usual” post-operative visits? Which post-op visits are “unusual” and therefore qualify for separate payment?

E/M Services Related to the Anesthesia Service

Checking on patients who are recovering uneventfully from anesthesia–aptly described by one Texas anesthesiologist as “howdy rounds”–generally does not result in billable E/M services. Even if the anesthesiologist were to document all the elements of a Level 1 (CPT™ code 99231), Level 2 (99232) or Level 3 (99233) subsequent hospital care service, most payers would reject the claim on the grounds that it constituted a routine post-operative visit, i.e., part of the anesthesia service. The E/M service must be medically necessary as well as “unusual.”

The National Correct Coding Initiative (NCCI) specifies pairs of codes that may not be billed together for reasons ranging from anatomic impossibility (prostatectomy + oopherectomy) to unbundling of procedures. Chapter Two of the NCCI describes the principles of anesthesia coding and states clearly:

[R]outine postoperative evaluation is included in the basic unit for the anesthesia service. If this evaluation occurs after the anesthesia practitioner has safely placed the patient under postoperative care, neither additional anesthesia time units nor evaluation and management codes should be reported for this evaluation. Postoperative evaluation and management services related to the surgery are not separately reportable by the anesthesia practitioner except when an anesthesiologist provides significant, separately identifiable ongoing critical care services.

The above paragraph contains the general rule and also the exception: critical care services. In addition to ventilation management, the insertion of a Swan-Ganz catheter, the insertion of central venous pressure lines, and emergency intubations, critical care visits may be reported on the days before, the day of, and/or on days following the surgery. The critical care visit codes are 99291 (first 30-74 minutes) and 99292 (each additional 30 minutes). The CPT instructions state that critical care services less than 30 minutes in total duration should be reported using the “appropriate E/M code”—which the broadly-worded Anthem policy would appear to exclude.  Other payers, however, accept and pay for E/M codes for services in the post-operative period that meet all the conditions of 99291 except that they are for fewer than 30 minutes.

It is possible that the Anthem policy uses the term “E/M visits” in the strict sense and that it does not encompass codes 99291 and 99292, which would thus be allowable. If Anthem should happen to deny a claim for post-operative critical care services, the policy statement is sufficiently ambiguous to justify an appeal. At least two Medicare contractors, we note, have explicitly recognized that the anesthesia service does not include critical care. NHIC, one of the Medicare Administrative Contractors, last updated its Anesthesia Billing Guide in October 2010. The following policy appears on page 8:

Payment may be made under the fee schedule for specific medical and surgical services by the anesthesiologist as long as these services are reasonable and medically necessary or provided other rebundling provisions do not preclude separate payment. These services may be rendered in conjunction with the anesthesia procedure to the patient or as single services [and include] critical care visits.

In our January 31, 2011 Alert we discussed the lone-wolf behavior of a Medicare Recovery Audit Contractor (RAC), Health Data Insights (HDI), which had made a second pass at establishing an “issue” involving the bundling of visits with anesthesia services. In its first iteration, attempting to define a global package for anesthesia care, HDI had indicated that only critical care services would be allowed in the post-anesthesia period. The later version was silent on the question of whether post-operative E/M services could be reported separately. Hence the situation, as far as Medicare contractors, at least, are concerned, remains somewhat ambiguous. Private payers are of course free to implement their own rules, subject to the requirements of their contracts with employers and with participating providers as well as their state insurance regulations.

Post-Operative Pain Management

The Anthem policy would seem to apply to post-operative visits related to either the anesthesia or to pain management. The same sentence appears under the heading “Global Surgery” and under “Anesthesia.” This would suggest that the visits are considered bundled with the surgery, i.e., the pain procedure as well as with the anesthesia service. We have seen explanations of benefits that allow payment for nerve blocks (codes 64415-64416, 64445-64448, 64449) on the same day as the surgery while denying code 99231 on subsequent days. Anthem appears to be applying the policy to all E/M visits within the 10 days following surgery.

Again, the NCCI does not go that far. It provides:

Pain management performed by an anesthesia practitioner after the postoperative anesthesia care period terminates may be separately reportable.

Anesthesia practitioners if permitted by state law 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....

Pain management services subsequent to the date of insertion of the catheter for continuous infusion may be reported with CPT code 01996 for epidural/subarachnoid infusions and with evaluation and management codes for nerve block continuous infusions." (Emphasis added).

Thus while E/M codes would be inappropriate for post-anesthesia visits to check on epidurals and subarachnoid infusions, they are reportable for the post-operative management of nerve blocks as long as they are medically necessary, under the coding principles followed by Medicare and most payers.  The NHIC Billing Guide mentioned above bears out this principle:

Evaluation and management services for postoperative pain control on the day of surgery are considered part of the usual anesthetic services and are not separately reportable. When medically necessary and requested by the attending physician, hospital visits or consultative services are reportable by the anesthesiologist during the postoperative period. However, normal postoperative pain management, including management of intravenous patient controlled analgesia, is considered part of the surgical global package and should not be separately reported....

When these injection procedures [continuous block codes 64416, 64446, 64448, or 64449] constitute the main surgical anesthetic and are therefore not separately reported on the day of surgery, subsequent days' hospital managment is reported using the appropriate hospital visit code (99231-99233)....


Note the language, in the first of the two paragraphs quoted immediately above: “When medically necessary and requested by the attending physician, hospital visits or consultative services are reportable.” The key here is medical necessity plus a request by the attending, which the anesthesiologist must fully document. Writing “patient comfortable” on the medical record is not going to support the claim, if the payer questions medical necessity. The record should show, rather, that the anesthesiologist was called to check on the patient because of a complication such as itching, swelling, shortness of breath, nausea/vomiting, or sweating.

In order to bill for code 99231, the lowest level of inpatient follow-up care, the anesthesiologist must also satisfy and document the requirements of the code itself:

99231 Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is stable, recovering or improving. Physicians typically spend 15 minutes at the bedside and on the patient's hospital floor or unit.

Clinical examples in Appendix C of the 2011 official CPT code book demonstrate post-anesthesia visits that satisfy the history/exam/medical decision-making requirements for 99231:

  • Follow-up hospital visit for a 35-year old, status post-epidural analgesia.
  • Subsequent hospital visit for a 56-year old male, post-gastrectomy, for maintenance of analgesia using an intravenous dilaudid infusion.

It is becoming more difficult to get paid for post-anesthesia visits in general. Anthem is merely one of the most restrictive payers we have seen lately. If the visit is medically necessary, non-routine and consists of the problem-focused examination and history and medical decision-making specified by the applicable code, however, and these factors are documented, anesthesiologists should report the service, and consider appealing any denial. We will continue to work on behalf of our clients to obtain payment where all of the requirements are met. We encourage everyone to do likewise so that non-payment for all post-anesthesia visits does not become the de facto standard.

With best wishes,

Tony Mira
President and CEO