Advanced Coding: E/M, Medicine, and Anesthesia

Advanced Coding: E/M, Medicine, and Anesthesia

Over the years ASA has received a number of questions regarding the circumstances
that allow separate payment for Evaluation & Management (E&M) services provided
by anesthesiologists during the pre‐operative period. This article is intended to
provide some guidance on when such claims might be paid.
Payment for anesthesia services reported with CPT® codes 00100–01999 includes
the pre‐operative examination of the patient who will undergo the
anesthetic. There is no separate payment available for that exam, even if it takes
place at a time in advance of the day the anesthesia is provided or in a place Advanced Coding: E/M, Medicine, and Anesthesia
separate from the surgical/procedure location, such as a pre‐operative clinic.
E&M services that go beyond those provided as part of the “routine” preoperative
evaluation and preparation of the patient for the planned surgery and anesthesia
may meet the criteria for claiming separate payment in addition to payment for the underlying anesthesia service itself provided all relevant criteria are met and
documented. The services must be separately identifiable and significant E&M
services that are clearly beyond those necessary to evaluate the patient for
anesthesia or necessary to safely provide anesthesia services. To qualify as a
separate service, the anesthesiologist must provide services beyond the pre‐
operative anesthesia exam. In most cases this should include medical management
of underlying diseases to optimize the patient for the surgical procedure and
anesthesia. These could include a comprehensive evaluation of the patient’s
medical condition and management of those issues that need to be corrected or Advanced Coding: E/M, Medicine, and Anesthesia

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optimized prior to surgery and anesthesia, or managing the patient’s medical
conditions after the surgical procedure.
Separate charges for E&M services by anesthesiologists could raise red flags with
Medicare, Medicaid, the Office of the Inspector General (OIG) or Recovery Audit

Contractor (RAC) auditors, especially if this occurs more often than as a rare event.
When two services are reported together, the documentation should clearly indicate
not just what was done as far as providing services necessary to qualify for the
particular level of E&M code reported (history, physical exam, and medical decision
making), but also clearly demonstrate the medical necessity of the anesthesiologist
providing E&M services beyond those provided by the surgeon or the patient’s
primary care physician. It is not enough to document what was done, but also that Advanced Coding: E/M, Medicine, and Anesthesia
what was done was necessary for the treatment of that particular patient.
Claims for E&M services that are separate from the routine preoperative evaluation
and preparation for the planned anesthetic should be identified with the CPT code
that best describes the level of E&M services provided. To avoid RAC automated
review processes, a modifier should be added to the E&M code to describe the
particular circumstances surrounding the provision of those E&M services on the
day of or day prior to the anesthetic when the clinical situation supports use of the
modifier. The modifier most often used when reporting anesthesia services and a
separate E&M service is modifier 25 (significant, separately identifiable E&M service
by the same physician or other qualified health care professional on the same day of
the procedure or other service). It is not appropriate to add a modifier to the E&M
CPT code if the separate E&M service is provided prior to the day before surgery.
However, a RAC may still review claims if both services are provided within a
relatively short time period. In such cases even though no modifier is added to the
code, it is necessary that the medical documentation clearly demonstrate that the
E&M service was beyond the required preoperative anesthesia evaluation and that Advanced Coding: E/M, Medicine, and Anesthesia
those additional services were medically necessary.
During the initial RAC operations, one of the RACs initiated automated processes to
identify instances in which anesthesiologists submitted claims for an E&M service
on the day of or the day prior to an anesthesia service. The RAC would then recoup the payment for the E&M service as part of its automated process without reviewing
medical records to determine whether those services met criteria that would allow
separate payment for the E&M services. The ASA successfully demonstrated that in
many cases such payments could be proper and the combination of anesthesia
services and E&M services should not be subject to automatic recoupment. The Advanced Coding: E/M, Medicine, and Anesthesia
RACs may still review instances of claims for both anesthesia services and E&M
services, but in most cases now conduct complex reviews, which require the RACs to
notify the anesthesiologist of the review and allow them to submit medical records Notice: The ASA has used its best efforts to provide accurate coding and billing advice,
but this advice should not be construed as representing ASA policy (unless otherwise
stated), making clinical recommendations, dictating payment policy, or substituting for the
judgment of a physician.
to justify the separate reporting of the two services. Anesthesiologists receiving
requests for such documentation must submit it within the required time frames or
the RAC can proceed with its recoupment activities Advanced Coding: E/M, Medicine, and Anesthesia