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Editor's Note: This article by Paul Cadorette, director of education for mdStrategies, originally appeared in The Coding Advocate, mdStrategies free monthly newsletter. Sign-up to receive this newsletter by clicking here.
Manipulation under anesthesia is a treatment that includes manipulation of multiple body joints for chronic pain conditions and is performed in ASCs by orthopedic surgeons and specially trained chiropractors. According to insurance carriers such as Aetna and Cigna, there is a lack of evidence to establish this type of procedure as either being safe or effective in the treatment of musculoskeletal disorders. Ultimately, reimbursement will be decided by each individual carrier, but what I want to discuss is the fraud and coding abuse associated with this procedure.
Twilight anesthesia
This is the most common type of anesthesia administered for manipulation procedures. Twilight anesthesia is commonly known as IV sedation or conscious sedation. This is important because one of the main considerations for assigning manipulation CPT codes is the type of anesthesia being administered and the fact that these CPT codes having specific anesthesia requirements.
When it comes to anesthesia, I would like to direct you to CPT Assistant Special Edition 2006, which states, "Code descriptors that include the phrases "with anesthesia" or "requiring anesthesia" indicate that the work involved in performing that procedure requires anesthesia, whether it is general anesthesia, regional anesthesia, or monitored anesthesia care."
"Moderate (conscious) sedation is not an anesthesia service."
Based on this information, conscious sedation would not meet the anesthesia requirements for any codes that include the phrasing "with anesthesia" or "requiring anesthesia."
27275 – Manipulation, hip joint, requiring general anesthesia
27570 – Manipulation of knee joint under general anesthesia
These codes represent a classic example of incorrect CPT usage. Before reporting a CPT code, you must meet all of the requirements associated with that code. Even though these are manipulation codes, they require the procedure to be performed using general anesthesia.
When manipulation of the hip or knee joint is performed under "twilight anesthesia," as is common with manipulation procedures — the anesthesia requirement for codes 27275 and 27570 has not been met so these CPT codes cannot be reported.
22505 – Manipulation of the spine requiring anesthesia, any region
Note that this code includes the statement "any region" — when reporting CPT code 22505, this code is reported one time for any and all regions (cervical, thoracic, lumbar) manipulated on a given date of service. It is not appropriate to report this code one time for the cervical region, one time for the thoracic region and one time for the lumbar region. Even more egregious are those instances where code 22505 is reported twice per region once because the patient was manipulated while laying on their right side and then rolled to their left side and manipulated again.
27194 – Closed treatment of pelvic ring fracture, dislocation, diastasis or subluxation; with manipulation, requiring more than local anesthesia
Code 27194 states that this is a treatment for pelvic ring fracture, dislocation, diastasis or subluxation, so in order to report this code, one of these conditions should be present, listed as the diagnosis and treatment should be performed for that condition. However, in a majority of the cases, pelvic pain or pelvic dysfunction is the diagnosis and muscle stretching is performed to try and alleviate the patient's "chronic pain." When you combine the diagnosis (pelvic pain) and the treatment performed (muscle stretching), it does not meet the intent of CPT code 27194, which is to treat pelvic ring fracture, dislocation, diastasis or subluxation. This indicates it would not be appropriate to report this code.
Keep in mind that when you submit a claim, you are confirming to the carrier that you understand and have complied with their payment policies and that correct coding guidelines have been followed.
The information provided should be utilized for educational purposes only. Please consult with your billing and coding expert. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.
Related Articles on Coding, Billing & Collections:
How ASCs Can Build Process Improvement and Lean Principles Into Billing
Survey: 46.3 Million Americans Without Health Insurance
16 Tips for Optimizing an ASC's Revenue Cycle
Editor's Note: This article by Paul Cadorette, director of education for mdStrategies, originally appeared in The Coding Advocate, mdStrategies free monthly newsletter. Sign-up to receive this newsletter by clicking here.
Manipulation under anesthesia is a treatment that includes manipulation of multiple body joints for chronic pain conditions and is performed in ASCs by orthopedic surgeons and specially trained chiropractors. According to insurance carriers such as Aetna and Cigna, there is a lack of evidence to establish this type of procedure as either being safe or effective in the treatment of musculoskeletal disorders. Ultimately, reimbursement will be decided by each individual carrier, but what I want to discuss is the fraud and coding abuse associated with this procedure.
Twilight anesthesia
This is the most common type of anesthesia administered for manipulation procedures. Twilight anesthesia is commonly known as IV sedation or conscious sedation. This is important because one of the main considerations for assigning manipulation CPT codes is the type of anesthesia being administered and the fact that these CPT codes having specific anesthesia requirements.
When it comes to anesthesia, I would like to direct you to CPT Assistant Special Edition 2006, which states, "Code descriptors that include the phrases "with anesthesia" or "requiring anesthesia" indicate that the work involved in performing that procedure requires anesthesia, whether it is general anesthesia, regional anesthesia, or monitored anesthesia care."
"Moderate (conscious) sedation is not an anesthesia service."
Based on this information, conscious sedation would not meet the anesthesia requirements for any codes that include the phrasing "with anesthesia" or "requiring anesthesia."
27275 – Manipulation, hip joint, requiring general anesthesia
27570 – Manipulation of knee joint under general anesthesia
These codes represent a classic example of incorrect CPT usage. Before reporting a CPT code, you must meet all of the requirements associated with that code. Even though these are manipulation codes, they require the procedure to be performed using general anesthesia.
When manipulation of the hip or knee joint is performed under "twilight anesthesia," as is common with manipulation procedures — the anesthesia requirement for codes 27275 and 27570 has not been met so these CPT codes cannot be reported.
22505 – Manipulation of the spine requiring anesthesia, any region
Note that this code includes the statement "any region" — when reporting CPT code 22505, this code is reported one time for any and all regions (cervical, thoracic, lumbar) manipulated on a given date of service. It is not appropriate to report this code one time for the cervical region, one time for the thoracic region and one time for the lumbar region. Even more egregious are those instances where code 22505 is reported twice per region once because the patient was manipulated while laying on their right side and then rolled to their left side and manipulated again.
27194 – Closed treatment of pelvic ring fracture, dislocation, diastasis or subluxation; with manipulation, requiring more than local anesthesia
Code 27194 states that this is a treatment for pelvic ring fracture, dislocation, diastasis or subluxation, so in order to report this code, one of these conditions should be present, listed as the diagnosis and treatment should be performed for that condition. However, in a majority of the cases, pelvic pain or pelvic dysfunction is the diagnosis and muscle stretching is performed to try and alleviate the patient's "chronic pain." When you combine the diagnosis (pelvic pain) and the treatment performed (muscle stretching), it does not meet the intent of CPT code 27194, which is to treat pelvic ring fracture, dislocation, diastasis or subluxation. This indicates it would not be appropriate to report this code.
Keep in mind that when you submit a claim, you are confirming to the carrier that you understand and have complied with their payment policies and that correct coding guidelines have been followed.
The information provided should be utilized for educational purposes only. Please consult with your billing and coding expert. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.
Related Articles on Coding, Billing & Collections:
How ASCs Can Build Process Improvement and Lean Principles Into Billing
Survey: 46.3 Million Americans Without Health Insurance
16 Tips for Optimizing an ASC's Revenue Cycle