Twenty for Twenty: The Top 20 Highlights for Anesthesia in 2020

    With every new year there is the prospect of change.  It’s the primary role that January 1 seems to always play: an objective demarcation and psychological delineation between what was and what will be.  It’s a time of personal change, with millions making resolutions to lose weight or forgo certain habits.  A new year means new laws, as well, with thousands taking effect on the first of January in the several states, as well as nationally.  It, therefore, comes as no surprise that each January brings change to the anesthesia specialty, with new codes and new requirements that must be reviewed and implemented.

    Our last alert acted as a review of the primary issues that affected anesthesia practices in 2019.  This alert will attempt to encapsulate the top 20 coding and other changes that will apply to anesthesia practices in 2020.  For each category listed below, we will provide a summary of whether or not there was a change for 2020; and, if so, the extent of the change.

    1. Reimbursement. As we’ve previously reported, the 2020 Medicare national conversion factor (CF) for anesthesia decreased from $22.2730 to $22.2016.  The 2020 CF for surgical services increased slightly from $36.0391 to $36.0896.  Most of the nerve block codes were revalued for 2020, reflecting an overall reduction in payment. 
    2. New Anesthesia Codes There are no new anesthesia codes for 2020.  However, there are new codes affecting anesthesia in the surgical section of the CPT coding manual (as detailed further below). 
    3. Deleted Anesthesia Codes.  There are no deleted anesthesia codes for 2020.  There were three nerve block codes that were deleted (discussed below). 
    4. Amended Anesthesia Codes.  There are no amended anesthesia codes for 2020.  There are some amended nerve block codes that are discussed below. 
    5. Lines and TEEs.  The CPT codes for arterial lines, central lines, PA catheters, and TEEs have remained unchanged. 
    6. Amended Intercostal Nerve Block Codes.  These blocks are typically used for acute post-surgical pain relief.  In the past (2019), one either coded CPT 64420 (single) or 64421 (multiple); it was one or the other, but not both.  For 2020, blocking multiple levels would involve coding both 64420 (single) and 64421 (each additional level).

      So, there are two changes.  First, 64421 becomes an add-on code, not an “either/or” code.  Second, you can code one unit of 64421 for each additional intercostal nerve block done in excess of the initial level.  For example, if you blocked 4 nerves from T5-T8, we would code 64420 x1 and 64421 x 3.

      Since 64421 is an add-on code, the RT and LT modifiers (rather than the bilateral 50 modifier) would be appended.  However, the 50 modifier would be appended to the primary code, 64420, where applicable. 

    7. Nerve Block Codes Allow for Imaging.  The American Medical Association (AMA) says that CPT codes 64400-64450 (somatic nerve injections) do not include/bundle image guidance.  This allows anesthesia providers to continue to separately bill for imaging (e.g., ultrasound guidance) in connection with this particular code set.  Most of the other nerve block codes bundle image guidance.  There is a new table on p. 437 of the Professional Edition of CPT 2020 which lists all the nerve block codes and shows which codes allow or bundle separate payment for imaging. 
    8. Nerve Block Codes Allow for Steroids.  The descriptors for 64400-64450, discussed immediately above, were amended to allow for the injection of a steroid as part of the code definition.  Previously, the descriptors to these codes stated, “Injection(s), anesthetic agent(s).”  Now, the descriptors add the words “and/or steroid.” 
    9. Deleted Nerve Block Codes The following three nerve block codes have been deleted from the CPT Code for 2020:
      • 64402 – Injection, anesthetic agent; facial nerve
      • 64410 – Injection, anesthetic agent; phrenic nerve
      • 64413 – Injection, anesthetic agent; cervical plexus
    10. ASA RVG Parenthetical Change. Even though there are no new anesthesia codes, the Relative Value Guide (RVG), published by the American Society of Anesthesiologists (ASA), includes recommendations on the use of certain codes within parenthetical statements located under the code in question. While there are no new recommendations within the RVG, that publication does contain one revised parenthetical statement for 2020. Specifically, the existing parenthetical note for CPT 00326 (anesthesia for procedures of the larynx and trachea in children under one) is amended to clarify that a tracheobronchial reconstruction would be reflected by CPT 00539 (18 units), rather than 00326 (8 units).
    11. 2020 ASA Crosswalk Changes and Updates. Each year the ASA’s Crosswalk manual makes changes to certain anesthesia “cross-codes.” Each surgical CPT code is crossed to a recommended anesthesia code or alternate anesthesia code(s) that best reflects the most appropriate code for the surgical case. When a change is made to a cross-code, this reflects the ASA’s changing thinking as to the most appropriate anesthesia code for a particular surgical procedure. Some of the changes for 2020 resulted in increased base units because of higher-paying cross-codes, while others resulted in decreased base units. A synopsis of a few of the more interesting changes is provided below.
    • Increased Base Units: Second Level Interspinous Process Devices (CPT 22868 and 22870)
      • 2019 – No ASA cross (add-on code)
      • 2020 – 00670/13 units
      • ASA Comment: These add-on procedures substantially increase the procedure
      • Example: First level only (22867 or 22869) = 00630/8 unit, but second level add-on codes (22868 or 22870) = 00670/13 units 
    • Increased Base Units: Removal & Replacement of Pacemaker Pulse Generator (CPT 33227, 33228 and 33229)
      • 2019 – 00400/3 units
      • 2020 – 00530/4 units
      • Removal without replacement (33233) still crosses to 00400/3 units
    • Increased Base Units: Remove Defibrillator Electrode via Transvenous Extraction (CPT 33244)
      • 2019 – 00400/3 units
      • 2020 – Primary cross: 00520/6 units; alternate cross: 01926/10 units
      • ASA Comment: Report alternate when there is extensive intracardiac work and manipulation of the leads and use of a laser to remove adhesions
    • Increased Base Units: Inguinofemoral lymphadenectomy, superficial (CPT 38760)
      • 2019 – 00400/3 units
      • 2020 – 01250/4 units
    • Increased Base Units: Alternate Code Added for Egg Retrieval (CPT code 58970)
      • Primary cross: 00940/3 units
      • The alternate cross of 00840/6 units has new instructions: use for percutaneous laparoscopic follicle puncture
    • Decreased Base Units: There are no codes with decreased base units for 2020.
    • Codes with No Crosses. A number of existing CPT codes (63 of them) no longer have an anesthesia cross-code for 2020. These codes are defined as “Anesthesia Care Not Typically Required.” The following comment was added for all codes that are so defined: “Although anesthesia care is not typically required, coverage/payment should not be routinely denied when medically necessary.”

    12. Bilateral Indicator for Add-on Codes. In a move that will undoubtedly cause confusion to coders and payers alike, the AMA instructs providers to avoid use of the 50 modifier with add-on codes (such as additional level intercostal nerve blocks and paravertebral blocks), while still using the 50 modifier for the initial level codes. The additional level codes will be billed on separate line items with LT and RT, as applicable.

    So, for example, a three-level bilateral intercostal nerve block would be coded as 64420-50 (initial level), 64421 LT (2nd level left), 64421 RT, (2nd level right), 64421 LT-76 (3rd level left) and 64421 RT-76 (3rd level right). The same applies to paravertebral blocks. To emphasize the new rule, Appendix A to the 2020 CPT manual (Modifiers) adds a sentence to the definition of the 50 modifier which states, “Note: This modifier should not be appended to designated ‘add-on’ codes (see Appendix D).” Appendix D is the list of all the add-on codes in the CPT manual.

    13. Colonoscopies. In the 2020 Medicare Physicians Fee Schedule (MPFS) Final Rule, Medicare again states that if a polyp or biopsy is taken during a screening colonoscopy, the service is no longer coded as a screening colonoscopy, CPT 00812. Instead, one would list the code for diagnostic colonoscopy, 00811 PT—in which case, the patient is charged the 20% copay. Medicare also states that a positive Cologuard or fetal occult blood test that is the basis for a colonoscopy constitutes a diagnostic colonoscopy, not a screening colonoscopy.

    14. Pre-anesthesia Eval by CRNA in ASC. For those of you using CRNAs to provide anesthesia in an ambulatory surgery center (ASC), the federal regulation at 42 CFR 416.42(a)(1), which requires a physician to perform the pre-anesthesia evaluation, will be amended to allow an anesthetist to perform that service. CMS has historically allowed the CRNA to perform the post-anesthesia evaluation in an ASC, as well as the pre- and post-anesthesia evaluation in the hospital setting; now, anesthetists will be allowed to also perform the pre-anesthesia evaluation in the surgery center setting. Keep in mind that regardless of setting, a physician must always perform the pre-anesthesia assessment if the CRNA is being medically directed.

    15. MIPS. The Multimodal Pain Management measure is being added to the anesthesiology specialty set. This tracks the percentage of patients 18 and over undergoing surgical procedures who were managed with multimodal pain medicine. While most anesthesia providers will be exempt from having to participate in MIPS, some may nevertheless choose to voluntarily participate in the program through mechanisms such as a qualified registry.

    16. Teaching Physicians. For Medicare, a physician, resident, or nurse may document in the medical record that the teaching physician was present and appropriately participated. This includes evaluation and management (E/M) visits.

    17. X Modifiers in Lieu of Modifier 59. While the X modifiers are not yet required, the 2020 version of the National Correct Coding Initiative (NCCI) gives the following examples related to anesthesia usage of the X modifiers:

    • XU can be used to report post-op pain blocks. See NCCI, Chapter 2, p. II-6.
    • XU can be used to report vent management on the same day as anesthesia, but only after anesthesia has transferred patient care to another physician. See NCCI, Chapter 2, p. II-11.
    • XU can be used if the surgeon requests anesthesia to perform a procedure during the surgeon’s global period that is beyond the surgeon’s experience. See CCI, Chapter 2, p. II-12.

    18. New Genicular and SIJ Codes. While these codes are listed in the RVG, these are primarily used as chronic pain procedures and will be addressed in a separate article providing an update of chronic pain for 2020.

    19. Relaxed Documentation Standards. Federal regulations found at 42 CFR 410.20(e) and 42 CFR 410.69, relating to physicians and CRNAs respectively, will be amended to allow both physicians and CRNAs to review and verify (sign and date), rather than re-document, notes in a patient’s medical record produced by other members of the medical team.

    20. Surprise Medical Bills. Four more states have enacted laws, with effective dates of January 1, 2020, that address so-called “surprise medical bills.” The states of Colorado, New Mexico, Washington and Texas have produced measures that make it more difficult for out-of-network providers to “balance-bill” patients who receive surgical services by in-network surgeons at in-network facilities. Other states, such as New York, Florida and California, have already enacted similar statutes, and we are anticipating the passage of a national balance-billing law by Congress in the near future.

    These are our “twenty for twenty”—the top 20 coding and ancillary highlights for anesthesia practices in 2020.  Be sure to keep this as a resource as you will want to refer back to it throughout the year.  In the meantime, if we can help you assess the impact of any of these changes on your practice, please do not hesitate to contact you account executive.  We want to have a part in making this your best year yet.  Warm wishes for 2020!

    We wish to thank healthcare attorney David Vaughn for his contribution in pulling together much of the above material. As always, you can reach us at