Warning: Just including EGD diagnosis with your claim doesn’t guarantee reimbursement — here’s help.
Question: Our anesthesiologist provided anesthesia during an esophagogastroduodenoscopy (EGD) procedure, at the request of the attending physician. We coded the anesthesia portion with 00810. A note in the documentation mentions the request was due to the patient’s symptoms, but no other details were provided. The claim we submitted was denied, but we followed all of the other guidelines provided by the payer, including proof that the anesthesiologist administered Propofol. What did we do wrong?
Answer: One key to the denial might be found in the lack of coding for the patient’s condition. Your diagnosis code should indicate the co-existing medical condition that justifies your anesthesiologist’s involvement in the case, not the gastrointestinal condition leading to the endoscopy.
You may want to consult with your anesthesiologist to verify that the patient had a condition such as:
- Parkinson’s disease (332.0)
- Heart conditions (such as 410.xx, Acute myocardial infarction or 427.41, Ventricular fibrillation)
- Mental retardation (318.x)
- Seizure disorders (such as 780.39, Other convulsions)
- Anxiety (such as 300.0x, Anxiety states)
- Pregnancy
- History of drug or alcohol abuse.
These are just some of the conditions that payers may require to justify the presence of an anesthesiologist at a colonoscopy. ICD-9 2010 also has two codes to describe failed sedation attempts: 995.24 (Failed moderate sedation during procedure) and V15.80 (Personal history of failed moderate sedation).
If your anesthesiologist’s documentation confirms one of these conditions, 995.24 or V15.80 would also justify an anesthesiologist’s involvement to most payers. The conditions listed above constitute the medical necessity of anesthesia with the procedure. If you used a screening diagnosis or treatment of commonly found conditions instead of the clinical condition requiring anesthesia, payers will not pay you for these services.
Also note the number of other possible elements that may need to be met for proper reimbursement of EGD anesthesia, including documentation noting the patient’s physical status. For example, some payers require a physical status modifier of P3 (A patient with severe systemic disease) or higher.
Caution: Including the diagnosis with your claim doesn’t guarantee reimbursement. You might head off future denials by verifying EGD coverage with your payer beforehand. While EGD procedures are still a complex area for anesthesia coders, payers continue to have varying requirements for use of anesthesia in EGD procedures.
Good news: Your use of 00810 (Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum) is correct, based on when the physician likely introduced the endoscope.
@ Anesthesia & Pain Management Coding Alert. Editor: Joshua Thines
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