Figure out the missing EGD reimbursement link

A word of caution: Just including EGD diagnosis with your claim does not ensure reimbursement – here is help.

Question: Our anesthesiologist provided anesthesia during an esophago gastroduodenoscopy (EGD) procedure, at the request of the attending doctor; we coded the anesthesia portion with 00810. A note in the documentation says that the request was owing to the physician's symptoms, however no other details were provided. The claim we submitted was denied, however we followed all of the other guidelines provided by the payer, including proof that the anesthesiologist administered Propofol. So where did we go wrong?

Answer: One solution to the denial might be found in the lack of coding for the patient's condition. Your diagnosis code should point to 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 like:

Parkinson's disease (332.0) Heart conditions (like 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 some of the conditions that payers may need 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 corroborates one of these conditions, 995.24 or V15.80 would also justify an anesthesiologist's involvement to most payers. The conditions mentioned above comprise the medical necessity of anesthesia with the procedure.

If you used a screening diagnosis or treatment of commonly found conditions in place of the clinical conditioning needing anesthesia, payers will not pay for these services. What's more, the number of other likely elements that may need to be met for right reimbursement of EGD anesthesia, including documentation noting the patient's physical status. For instance, some payers call for a physical status modifier of P# (A patient with severe systematic disease) or higher. A word of caution: Including the diagnosis with your claim does not guarantee money. You might do away with future denials by verifying EGD coverage with your payer ahead of time. While EGD procedures are still a tough area for anesthesia coders, payers continue to have changing requirements for use of anesthesia in EGD procedures. Good tidings: Your use of 00810 (Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum) is right, based on when the doctor likely introduced the endoscope.