AAPC Chapter 16 - Anesthesia - Practical Application Cases 1-10 2022

Anesthesiologist personally performed case(Use modifier AA to indicate the Anesthesiologist personally performed the case.) Anesthesia Time: 13:04 to 13:41(Anesthesia time is 37 minutes.) Physical Status: 3(Physical status 3 ‑ use P3 modifier.) PREOPERATIVE DIAGNOSIS: RLL Lung Cavity, possible CA of lung POSTOPERATIVE DIAGNOSIS: Right Lower Lobe Lung Carcinoma(Post-operative diagnosis confirms RLL CA.) PROCEDURE: Bronchoscopy(Procedure performed.) ANESTHESIA: Monitored Anesthesia Care(Use modifier QS to indicate monitored anesthesia care was used.) PROCEDURE DESCRIPTION: With the patient under satisfactory anesthesia, a flexible fiberoptic bronchoscope was introduced via oral cavity and advanced past the larynx for visualization of the bronchus. Cell washings were obtained and sent to pathology. The bronchoscope was then removed. Patient tolerated procedure well. Cell washings obtained from the right lower lobe were confirmed by pathology as malignant carcinoma. What CPT® and ICD-10-CM codes are reported for the anesthesiologist?

Correct Answer 00520-AA-QS-P3 C43.31 37

ANES Start: 14:07 ANES End: 17:33 (Total anesthesia time 3 hours 26 minutes, or 206 minutes.) Physical Status: 3 Anesthesiologist: Michael D, MD (Physical status 3, use modifier P3. Personally performed by the anesthesiologist, use modifier AA.) Operative report Preoperative diagnosis: Lumbar spinal stenosis Postoperative diagnosis: L4-L5 spinal stenosis (Post-operative diagnosis of lumbar (L4-L5) stenosis.) Procedure: L4-5 laminectomy, removal of synovial cyst, bilateral medial facetectomy and posterolateral fusion L4-L5 with vertebral autograft, bone morphogenic protein, chip allograft, all with intraoperative somatosensory evoked potentials, electromyographies and loupe magnification. (The following procedures were performed: L4-5 laminectomy, removal of synovial cyst, bilateral medial facetectomy and posterolateral fusion L4-L5 with vertebral autograft, bone morphogenic protein, chip allograft, all with intraoperative somatosensory evoked potentials, electromyographies and loupe magnification. The Laminectomy is more complex and carries a higher base value.) Anesthesia: General endotracheal (Type of anesthesia is general.) anesthesia. Description of Procedure: The patient was taken to the operating room and underwent intravenous anesthetic and orotracheal intubation. Her head was placed in the three-pin Mayfield headrest. She was turned into the prone position on a four-poster frame. All pressure points were carefully padded. The fluoroscope was brought in and sterilely draped to help localize the incision. A midline incision was made between L4 and L5 through skin and subcutaneous tissue and the paraspinal muscles were dissected free of the spinous process, lamina, facets and L4, L5 transverse processes. Self-retainers were placed more deeply. We proceeded to use the double-action rongeur to remove the L4-L5 spinous process lamina. 3 and 4 millimeter Kerrison punches were used to complete the laminectomy including removing the hypertrophied ligamentum flavum. We made sure that we decompressed from the top of the L4 pedicle to the bottom of the L5 pedicle, which was confirmed with intraoperative fluoroscopy. The medial facets were drilled and then we undercut over the nerve roots with a 3 millimeter Kerrison punch. Hemostasis was achieved with powdered gelfoam. We irrigated the wound. We decorticated the L4 and L5 transverse processes. We placed our vertebral autograft, bone morphogenic protein and chip allograft in the posterolateral gutters. Hemovac drain was placed. We closed the muscle with 0 Vicryl. Fascia was closed with 0 Vicryl. Subcutaneous tissue was closed with 2-0 Vicryl and the skin was closed with staples. What CPT® and ICD-10-CM codes are reported for the anesthesiologist?

Correct Answer 00630-AA-P3 M48.061 206

Anesthesia services personally provided by anesthesiologist(Use modifier AA to indicate the anesthesia was personally performed by the anesthesiologist.) Physical Status: 2(Physical status 2, use modifier P2.) Anesthesia Start: 10:03 - Anesthesia Stop: 11:06 (Anesthesia time is 1 hour and 3 minutes, or 63 minutes.) PREOPERATIVE DIAGNOSIS: Sternal wound hematoma. POSTOPERATIVE DIAGNOSIS: Complicated upper abdominal wall wound.(Postoperative diagnosis used for coding if no other indication is found in the operative note.) NAME OF PROCEDURE: Sternal wound exploration and wound vac placement.(Procedure performed.) ANESTHESIA: Monitored Anesthesia Care(Use modifier QS to indicate MAC is used.) BRIEF HISTORY: He is a 52-year-old patient who is two weeks out from re-do sternotomy and aortic valve replacement for critical aortic stenosis in the setting of heart failure. He had a postoperative coagulopathy and required sternal re-exploration with open packing.(The wound is a post-operative complication.) He was closed the next day. He had serous discharge prior to going home but this was culture negative and the wound looked very good. He continued to have serous discharge in the clinic and it was felt he had a retained hematoma. He was scheduled for evaluation of the hematoma and wound vac placement. This was done without incident. He did not have any evidence of infection. There was no evidence of any sternal instability. DESCRIPTION OF OPERATIVE PROCEDURE: Following delivery of the patient to the operating room, the patient was placed on the operating table, prepared and draped in the usual sterile manner. His upper abdominal wound was explored. There was hematoma at the base of the wound which was very carefully evacuated(Confirms a postoperative hematoma.) and the wound was irrigated with antibacterial solution. A wound vac was then placed with the assistance of the wound care nurse.(Wound vac placed by a wound care nurse.) The patient was returned to the PCU in stable condition. What CPT ® and ICD-10-CM codes are reported for the anesthesiologist?

Correct Answer 00700-AA-QS-P2 L76.32 63

ANES Start: 12:18 ANES End: 13:31 (Reported anesthesia time in minutes.) CRNA: John Sleep, CRNA (Non-Medically Directed)(Modifier QZ used to indicate services are performed by a CRNA with no medical direction.) ASA Physical Status: 3 (Physical status 3—use modifier P3.) Operative Report Preoperative diagnosis: Stricture of the left ureter, postoperative Postoperative diagnosis: SAME(Postoperative diagnosis is the same as preoperative which is stricture of the left ureter, postoperative.) Procedure: 1. Cystoscopy of ileal conduit. 2. Exchange of left nephroureteral catheter. Anesthesia: Monitored anesthesia care.(Modifier QS is used to indicate MAC.) Description of Procedure: The patient is identified in the holding area, marked, taken to the operating room. Subsequently, she was given monitored anesthesia care. She was prepped and draped in the usual sterile fashion in the supine position. Next, using a flexible cystoscope, the ileal conduit was entered. Cystoscopy was performed, which showed the ureteroileal anastomosis on the left with a stent protruding from it. There were no calcifications seen on the stent. Thus, the cystoscope was removed from the ileal conduit and then a super stiff wire was advanced through the nephroureteral catheter, up into the kidney. Once it was up there, then the catheter was taken off of the wire and then a new 8-French x 28-centimeter, nephroureteral ureteral catheter was advanced fluoroscopically into the level of the kidney. Once this was done and its position was confirmed fluoroscopically, the wire was pulled. A good curl was there fluoroscopically in the kidney, as the wire was pulled. A good curl was seen in the bladder and then the distal end was protruding out from the ileal conduit. This was placed in the ostomy bag and the patient was taken in stable condition to the recovery room. What CPT® and ICD-10-CM codes are reported for the CRNA?

Correct Answer 00860-QZ-QS-P3 N13.5 73

Anesthesiologist personally performed (Personally performed by anesthesiologist—use AA modifier.) Anesthesia Time: 7:12 to 10:08 (Time is 176 minutes.) Physical Status: 2 (Physical status 2, use P2 modifier.) PREOPERATIVE DIAGNOSIS: Suspected Prostate Cancer POSTOPERATIVE DIAGNOSIS: Prostate Carcinoma (Post-operative diagnosis.) PROCEDURE: Radical Retropubic Prostatectomy (Procedure performed. Make note the procedure is "radical.") ANESTHESIA: General (General anesthesia.) What CPT® and ICD-10-CM codes are reported for the anesthesiologist?

Correct Answer 00865-AA-P2 C61 176

CRNA directly supervised by anesthesiologist who is directing two other cases. CRNA inserted a separate CVL, Swan-Ganz catheter, and an A-line Patient has a severe systemic disease that is a constant threat to life Anesthesia Time: 11:43 to 15:26 PREOPERATIVE DIAGNOSIS: Multivessel coronary artery disease. POSTOPERATIVE DIAGNOSIS: Coronary artery disease, native artery NAME OF PROCEDURE: Coronary artery bypass graft x 3, left internal mammary artery to the LAD, saphenous vein graft to the obtuse marginal, saphenous vein graft to the diagonal. ANESTHESIA: General BRIEF HISTORY: This 77-year-old patient who was found to have a huge aneurysm. Preoperative cardiac clearance revealed a markedly positive stress test and cardiac catheterization showed critical left-sided disease. Coronary revascularization was recommended. The patient has multiple medical illnesses including chronic obstructive pulmonary disease with emphysema and chronic renal insufficiency. I discussed with the patient and the family, the risks of operation including the risk of bleeding, infection, stroke, blood transfusion, renal failure, and death. At operation, we harvested a vein from the left leg using an endoscopic technique that turned out to be a very good conduit. Her obtuse marginal vessel was a 1.5-mm diffusely diseased vessel that was bypassed distally as it ran in the left ventricular muscle. The diagonal was a surprisingly good vessel at 1.5-mm in size. The LAD was bypassed in the mid aspect of the LAD and there was distal disease though a 1.5-mm probe passed quite easily. Good flow was measured in the graft. The patient came off bypass very nicely. Note should be made that her ascending aorta was calcified and we used a single clamp technique. DESCRIPTION OF OPERATIVE PROCEDURE: Following delivery of the patient to the operating room, the patient was placed under general anesthetic, was prepped and draped in the usual sterile manner. Arterial line through the skin, right pulmonary artery catheter and a left subclavian central lines were placed by the Anesthesia Department. A median sternotomy was made and the left internal mammary artery was harvested from the left chest wall, the saphenous vein was harvested from the left leg. The patient was heparinized and cannulated and placed on cardiopulmonary bypass |8| with an aortic cannula on the undersurface of the aortic arch and a venous cannula through the right atrial sidewall. Note should be made that the upper aorta was very heavily calcified, but the area that we cannulated was felt to be disease free. The aorta was cross clamped and the heart was stopped with antegrade and retrograde cardioplegic solution. The heart was retracted out of the pericardial sac and then displaced into the right chest which afforded good access to the lone marginal vessel which was bypassed with a reversed saphenous vein graft using a running 7-0 Prolene suture. Cold cardioplegic solution was then instilled down this graft. Note should be made that during the mammary artery harvest, the left lung was completely adherent to the left chest wall, most likely from old episodes of pneumonia. Next, a second saphenous vein segment was placed to the diagonal vessel and then the left internal mammary artery was placed to the mid LAD. As noted, there was diffuse calcification distally in this artery just beyond the anastomosis, but the 1.5 mm probe passed very nicely and we felt that it was not necessary to double jump this LAD. With the cross clamp in place, two proximal aortotomies were made and the two proximal anastomoses were formed using 6-0 Prolene in a running fashion. Just prior to completion of the second anastomosis, appropriate de-airing maneuvers were performed and then the suture lines were tied as the cross clamp was removed. The patient was allowed to rewarm completely and was weaned from bypass. The cannulas were removed and the cannulation sites were secured with pursestring sutures. Once hemostasis was secured, chest tubes were placed and the wound was closed. Final needle, instrument, and sponge counts were reported as correct. The patient tolerated the procedure well and returned to the recovery room in stable condition. What CPT® and ICD-10-CM codes are reported for the anesthesiologist? CPT® codes: [a], [b] ICD-10-CM code: [c] What CPT® and ICD-10-CM codes are reported for the CRNA? CPT® codes: [d], [e], [f], [g] ICD-10-CM code: [h] What is the time reported for this service? [i] minutes

Correct Answer a. 00567-QK-P4 b. 99100 c. I25.10 d. 00567-QX-P4 e. 36556-59 f. 93503 g. 36620-51 h. I25.10 i. 223 Response Feedback: CPT® Codes: The procedure performed was a CABG (Coronary Artery Bypass Graft). To locate the service in the CPT® Index, look for Anesthesia/Heart/Coronary Artery Bypass Grafting referring you to 00566, 00567. Selecting between the two codes depends on the use of a pump oxygenator. The documentation states "...the patient was placed on cardiopulmonary bypass..." indicating with pump oxygenator. 00567 is the correct anesthesia code. The patient is identified as having severe systemic disease that is a constant threat to life, supporting a P4 modifier. For the CRNA, modifier QX is used to report the CRNA service with medical direction. Anesthesia modifiers precede physical status modifiers. The CRNA placed a central venous catheter in the left subclavian. Look in the CPT® Index for Central Venous Catheter Placement/Insertion/Central Non-tunneled. Code 36556 is reported because the patient is 77 years old. Next, a Swanz-Ganz catheter is placed in the right pulmonary artery. Look in the CPT® Index for Swanz-Ganz Catheter/Insertion referring you to 93503. A central line (36556) is bundled with code 93503. A Swan-Ganz catheter is a central line with multiple lumens, which is flow-directed into the pulmonary artery. Modifier 59 is required with 36556 to indicate that this central line is in another site and totally separate from 93503. The CRNA also inserted an A-line (arterial line), which is coded separately. Look in the CPT® Index for Arterial Catheterization referring you to See Cannulation, Arterial. Look for Cannulation/Arterial. Code 36620 is the correct for percutaneous insertion through the skin. Anesthesia modifiers are not used on surgical procedure codes. Modifier 51 is needed on 36620 for additional procedures performed during the same session. For the anesthesiologist, modifier QK indicates the medical direction of 2-4 concurrent cases. The anesthesia modifiers precede physical status modifiers. Code 99100 is also reported due to the patient being 77 years old. There is no indication that this is a Medicare beneficiary, so 99100 is reported. When directing, only the anesthesiologist reports 99100. ICD-10-CM Code: The diagnosis is stated as coronary artery disease, native artery. To find the ICD-10-CM code, look in the ICD-10-CM Alphabetic Index for Disease, diseased/artery/coronary referring you to I25.10. Verify code selection in the Tabular List. Time: The anesthesia time is stated as 11:43 to 15:26 (3:26 pm), which calculates to 3 hours 43 minutes or 223 minutes.

CRNA performed anesthesia under medical direction of anesthesiologist Anesthesiologist medically directing one case CRNA placed arterial line Anesthesia Time: 10:43 to 12:50 Physical Status: 3 PREOPERATIVE DIAGNOSIS: Left Renal Mass POSTOPERATIVE DIAGNOSIS: Same PROCEDURE: Left Partial Nephrectomy, Laparoscopic ANESTHESIA: General PROCEDURE DESCRIPTION: Abdominal wall insufflated. The laparoscope was placed through the umbilical port and additional trocars were placed into the abdominal cavity. Using the fiberoptic camera, the renal mass was identified and the diseased kidney tissue was removed using electrocautery. Minimal bleeding is noted. Instruments were removed and the abdominal incisions were closed by suture. Patient tolerated surgery well and was transferred to the Post Anesthesia Care Unit in satisfactory condition. What CPT® and ICD-10-CM codes are reported for the anesthesiologist? CPT® code: [a] ICD-10-CM code: [b] What CPT® and ICD-10-CM codes are reported for the CRNA? CPT® codes: [c], [d] ICD-10-CM code: [e] What is the time reported for this service? [f] minutes

Correct Answer a. 00862-QY-P3 b. N28.89 c. 00862-QX-P3 d. 36620 e. N28.89 f. 127

CRNA performed anesthesia Anesthesiologist medically directing two cases Anesthesia Time: 9:30 to 10:06 Physical Status: 3 PREOPERATIVE DIAGNOSIS: Cyst behind knee POSTOPERATIVE DIAGNOSIS: Baker's cyst PROCEDURE: Excision of Baker's cyst, knee ANESTHESIA: Monitored Anesthesia Care What CPT® and ICD-10-CM codes are reported for the anesthesiologist? CPT® code: [a] ICD-10-CM code: [b] What CPT® and ICD-10-CM codes are reported for the CRNA? CPT® code: [c] ICD-10-CM code: [d] What is the time reported for this service? [e] minutes

Correct Answer a. 01400-QK-QS-P3 b. M71.20 c. 01400-QX-QS-P3 d. M71.20 e. 36

CRNA performed anesthesia under medical direction of anesthesiologist Anesthesiologist medically directing three cases Anesthesia Time: 8:52 to 9:34 Physical Status: 1 PREOPERATIVE DIAGNOSIS: Phimosis, congenital POSTOPERATIVE DIAGNOSIS: Phimosis, congenital PROCEDURE: Circumcision on six-month-old boy ANESTHESIA: Monitored Anesthesia Care What CPT® and ICD-10-CM codes are reported for the anesthesiologist? CPT® codes: [a], [b] ICD-10-CM code: [c] What CPT® and ICD-10-CM codes are reported for the CRNA? CPT® code: [d] ICD-10-CM code: [e] What is the time reported for this service? [f] Minutes

a. 00920-QK-QS-P1 b. 99100 c. N47.1 d. 00920-QX-QS-P1 e. N47.1 f. 42

Non-medically directed CRNA performed anesthesia care and documented intra-operative placement of continuous femoral nerve catheter for post operative pain. Anesthesia Time: 7:18 to 9:10 Physical Status: 3 PREOPERATIVE DIAGNOSIS: Left knee osteoarthritis POSTOPERATIVE DIAGNOSIS: Left knee osteoarthritis, localized primary , Acute postoperative pain PROCEDURE: Total Knee Arthroplasty ANESTHESIA: General anesthesia provided for surgery. Surgeon requested postoperative pain management via continuous femoral catheter What CPT® and ICD-10-CM codes are reported for the CRNA? CPT® code(s): [a], [b] ICD-10-CM code(s): [c], [d] What is the time reported for this service? [e] minutes

a. 01402-QZ-P3 b. 64448-59-LT c. M17.12 d. G89.18 e. 112