December 10, 2018

In the arcane world of CPT coding, there has been much discussion recently about potential changes intended to simplify payment and documentation for visits and consults. While it is true that any potential change could impact our anesthesia clients, in this case there are two pieces of good news.

First, the implementation of the proposed changes to the Evaluation and Management (E&M) payment structure has been delayed two years, until 2021. Second, the situations that necessitate use of these E&M codes are minimal except for chronic pain specialists (for whom these codes are very important).

Still, it is worth noting three specific situations in which E&M codes are relevant to the anesthesia provider: cancelled cases, anesthesia consults and daily management of non-epidural catheters. Although they may not be common in the typical practice, E&M codes offer the only billing option for these situations. Failure to understand their relevance could result in lost revenue.

There are two types of cancelled cases: 1) those in which the case is cancelled before induction but after prep for anesthesia and 2) those in which the case is aborted after induction. In the first case, the provider is entitled to bill a subsequent hospital visit code (for inpatient cases) or applicable E&M code (for other than inpatient cases) based on documentation of the preoperative assessment.  Typically, this will result in a low-level E&M code.  If the case is cancelled after induction, it is reported as a normal anesthetic with base and time units, but the time is limited to the actual time spent. Consults are a little more complicated. From a billing perspective, a consult is a specific event that must include documentation of three things: 1) a request and reason for an evaluation of the patient, 2) a rendering of an opinion based on a review of the patient’s medical history and a physical examination, and 3) a report back to the requesting physician. These three elements are referred to as the three Rs, without which the encounter cannot be billed as a consultation.

These requirements are complicated by the fact that some payers, such as Medicare, do not recognize consultation codes. For these payers, a visit code can be used. Please note that anesthesia consults are separate and distinct from preoperative assessments, which are not separately billable.  Practices with a preoperative clinic or an effective perioperative surgical home may have some cases that meet the consult criteria.

With regard to catheter management, there are two scenarios. The daily management of an epidural catheter is billed with a well-recognized code, 01996, for which the documentation requirements are minimal. The provider must document an examination, i.e., the site; an evaluation of the patient’s pain; a future plan of care; and the provider who delivered the care. For non-epidural indwelling catheters such as interscalene, axillary or femoral nerve catheters, a subsequent hospital visit code is used instead for the daily management of the catheter. Coders will review the details provided to determine the appropriate level.

It’s also worth knowing that, although changes to the E&M fee structure will not be implemented until 2021, the following optional documentation changes will be coming in 2019 as part of CMS’s effort to streamline reporting requirements for clinicians.

• Elimination of the requirement to document the medical necessity of a home visit in lieu of an office visit.
• For established patients history and exam, when relevant information is already contained in the medical record, practitioners may choose to focus their documentation on what has changed since the last visit, or on pertinent items that have not changed, and need not re-record the defined list of required elements if there is evidence that the practitioner reviewed the previous information and updated it as needed.
• For new and established patients chief complaint and history, practitioners need not re-enter in the medical record information that has already been entered by ancillary staff or the beneficiary. The practitioner may simply indicate in the medical record that they reviewed and verified this information.

If you have questions about whether your practice is meeting the criteria for each of the billing scenarios above, please contact your account executive, who will be happy to coordinate a review of your documentation with our coding department. We also have a number of documentation templates that you might find helpful.

As chronic pain management specialists know, their subspecialty represents a different mode of practice involving the evaluation and diagnosis of chronic and intractable conditions. As such, the use of outpatient visit and consult codes is essential.  These physicians may well be significantly impacted by the proposed changes to the E&M fee schedules coming in 2021. We will provide more information on these changes when we receive confirmation of the new fee schedules’ implementation.

With best wishes,

Tony Mira
President and CEO