AAPC Chapter 16

Code 00940 Anesthesia for vaginal procedures (including biopsy of labia, vagina, cervix or endometrium); not otherwise specified has a base value of three (3) units. The patient was admitted under emergency circumstances, qualifying circumstance code 99140, which allows two (2) extra base units. A preanesthesia assessment was performed and signed at 2:00 a.m. PS 4 was assigned by the anesthesiologist. Anesthesia start time is reported as 2:21 am, and the surgery began at 2:28 am. The surgery finished at 3:25 am and the patient was turned over to PACU at 3:36 am, which was reported as the ending anesthesia time. Using fifteen-minute time increments and a conversion factor of $100, what is the correct anesthesia charge?

$1,200.00 Rationale: Determining the base value is the first step in calculating anesthesia charges and payment expected. Time reporting is the second step. Per Anesthesia Guidelines in the CPT® code book under the subheading Time Reporting: Anesthesia time begins when the anesthesiologist begins to prepare the patient for anesthesia in the operating room (or an equivalent area) and ends when the anesthesiologist is no longer in personal attendance, that is, when the patient may be safely placed under postoperative supervision. In the scenario above, base units equal three (3) plus two (2) emergency qualifying circumstances units, plus two (2) units for P4 (Base 3 + QC 2 + P4 2 = 7 units). Five (5) time units, in 15-minute increments, is calculated by taking the anesthesia start time (2:21) and the anesthesia end time (3:36) and determining one hour 15 minutes (75/15 = 5) of total anesthesia time. 12 units (7 + 5 = 12) are then multiplied by the $100 conversion factor (12 X $100 = $1,200.00). Note: Base unit values are not separately listed in the CPT®. The American Society of Anesthesiologists (ASA) determines the base unit value for anesthesia codes.

A 94-year-old patient (Medicare beneficiary) is having surgery to remove his parotid gland with dissection and preservation of the facial nerve. The surgeon has requested the anesthesia department place an arterial line. What CPT® coding is reported for anesthesia?

00100, 36620, 99100 Rationale: In the CPT® Index look for Anesthesia/Salivary Glands which directs you to code 00100. Reference the code in the numeric section to confirm that 00100 is the correct code. Hint - Coders may need to use the Surgery Section to determine that the parotid gland is included in the salivary glands. The arterial line placement is NOT included in the base value and may be reported separately with code 36620. In the CPT® Index look for Catheterization/Arterial System/Percutaneous. Due to patient's advanced age of 94, qualifying circumstance add-on code +99100 is also reported. Furthermore, because the patient is a Medicare beneficiary, we do not use Physical Status Modifiers as they are not accepted by Medicare.

A 78-year-old patient is undergoing lens surgery for cataracts. An anesthesiologist personally performed monitored anesthesia care (MAC). Which modifier(s) appropriately report(s) the anesthesiologist's service?

00142-AA-QS RATIONALE: An anesthesiologist who is personally performing administration of anesthesia reports the service with an AA modifier. Because the service was performed using MAC, a QS modifier is also reported.

A patient presents to the OR for a craniotomy with evacuation of a hematoma. What CPT® coding is reported for the anesthesiologist's services?

00211 Rationale: Look in the CPT® Index for Anesthesia/Head which directs you to codes 00210-00222, 00300 or Anesthesia/craniotomy which directs you to code 00211. Review the numeric section to determine that the correct code is 00211 as it includes verbiage for the evacuation of a hematoma.

A 43-year-old patient with a severe systemic disease is having surgery to remove an integumentary mass from his neck. What CPT® coding and modifier are reported for the anesthesia service?

00300-P3 Rationale: Look in the CPT® Index for Anesthesia/Neck which directs you to codes 00300, 00320-00322, 00350-00352 or Anesthesia/Integumentary System/Neck which directs you to code 00300. Refer to the numeric section to determine that code 00300 is the correct code. Review the Anesthesia Guidelines in the CPT® codebook to determine that physical status modifier P3 may be reported for a patient with severe systemic disease. The correct code is 00300-P3.

CASE 3 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? CPT® code(s): [a] ICD-10-CM code(s): [b] What is the time reported for this service?

00520-AA-QS-P3, C34.31, 37

Using the CPT® Index, look for anesthesia for a diagnostic thoracoscopy. Which of the following is the correct anesthesia code?

00528 Rationale: Look in the CPT® Index for Anesthesia/Thoracoscopy. All of these codes are related to thoracoscopy. Code 00528 describes a diagnostic procedure not using one-lung ventilation (OLV) utilization.

CASE 10 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? What CPT® and ICD-10-CM codes are reported for the CRNA? What is the time reported for this service?

00567-QK-P4, 99100, I25.10, 00567-QX-P4, 36556-59, 93503, 36620-51, I25.10, 223 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.

CASE 2 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? What is the time reported for this service?

00630-AA-P3, M48.061, 206

CASE 4 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? CPT® Code: [a] ICD-10-CM Code: [b] What is the time reported for this service?

00700-AA-QS-P2, L76.32, 63

Using the CPT® Index, locate the anesthesia code for laparoscopic cholecystectomy. Which of the following is the correct anesthesia code?

00790 Rationale: A cholecystectomy is the surgical removal of the gallbladder. The gallbladder is an intraperitoneal organ located in the upper abdomen. Look in the CPT® Index for Anesthesia/Abdomen/Intraperitoneal directing you to code range 00790-00797, 00840-00851. A review of the codes verifies 00790 as the correct code. Another Index option is to look for Anesthesia/Laparoscopy.

CASE 5 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? CPT® Code: [a] ICD-10-CM Code: [b] What is the time reported for this service?

00860-QZ-QS-P3, N13.5, 73

CASE 7 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? What CPT® and ICD-10-CM codes are reported for the CRNA? What is the time reported for this service?

00862-QY-P3, N28.89, 00862-QX-P3, 36620, N28.89, 127

CASE 1 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? CPT® code(s): [a] ICD-10-CM code(s): [b] What is the time reported for this service?

00865-AA-P2, C61, 176

CASE 8 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? What CPT® and ICD-10-CM codes are reported for the CRNA? What is the time reported for this service?

00920-QK-QS-P1, 99100, N47.1, 00920-QX-QS-P1, N47.1, 42

Mr. Johnson, age 82, having been in poor health with diabetes and associated peripheral neuropathy, is having a fem-pop bypass. The anesthesiologist documents he has severe systemic disease. What coding is correct for anesthesia?

01270-AA-P3, 99100 Rationale: Fem-pop bypass is an abbreviation for femoral-popliteal bypass of arteries in the upper leg. Look in the CPT® Index for Anesthesia/Bypass Graft/Leg, Upper which directs you to code 01270. Review the code in the Tabular List to determine the correct code is 01270. The qualifying circumstance code 99100 is added to indicate the extreme age of the patient. Modifier AA is added to indicate the anesthesia is personally performed by the anesthesiologist. Physical status modifier P3 indicates the patient has severe systemic disease. There is no mention of Medicare; therefore, 99100 is reported.

CASE 6 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?

01400-QK-QS-P3, M71.20, 01400-QX-QS-P3, M71.20, 36

CASE 9 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? What is the time reported for this service?

01402-QZ-P3, 64448-59-LT, M17.12, G89.18, 112

What is the anesthesia code for a shoulder arthroscopy which became an open procedure on the shoulder joint?

01630 Rationale: In the CPT® Index, look for Anesthesia/Arthroscopic Procedures/Shoulder which directs you to code range 01622-01638. Review the codes in the numeric section to determine 01630 is the appropriate code selection because the description of the code includes open or surgical arthroscopic procedures.

What is the anesthesia code for a cast application to the wrist?

01860 Rationale: Look in the CPT® Index for Anesthesia/Cast Application/Forearm, Wrist and Hand which directs you to 01860. Verify code selection in the numeric section.

A 22-year-old patient delivered a healthy baby boy by cesarean delivery with general anesthesia. The anesthesiologist performed all required steps for medical direction and was medically directing two other cases concurrently. Which modifier(s) report(s) the anesthesiologist and CRNA services?

01961-QK and 01961-QX RATIONALE: An anesthesiologist who is medically directing reports the service separately from the CRNA, depending on the number of concurrent cases. Because there was more than one concurrent (QY) case and fewer than five concurrent (AD) cases, the appropriate modifiers to report are QK for the physician claim and QX for the CRNA claim. A QZ modifier is reported when indicating a case is performed by a CRNA without medical direction by a physician.

A preanesthesia assessment was performed and signed at 10:21 am. Anesthesia start time is reported as 12:26 pm, and the surgery began at 12:37 pm. The surgery finished at 15:12 pm and the patient was turned over to PACU at 15:26 pm, which was reported as the ending anesthesia time. What is the anesthesia time reported?

12:26 pm to 15:26 pm (180 minutes) Rationale Per Anesthesia Guidelines in the CPT® codebook under the subheading Time Reporting: Anesthesia time begins when the anesthesiologist begins to prepare the patient for anesthesia in either the operating room (or an equivalent area) and ends when the anesthesiologist is no longer in personal attendance, that is, when the patient may be safely placed under postoperative supervision. Anesthesia start time (12:26) and the anesthesia end time (15:26) calculates as 3 hours or 180 minutes of total anesthesia time.

Mrs. Jones is a 90-year-old female having laparoscopic gallbladder surgery. Dr. Lot, the anesthesiologist for this case, documents she is a normal healthy person and begins to prepare the patient for surgery at 07:30 am. Surgery begins at 08:00 am. The surgery is concluded at 09:30 am. The anesthesiologist releases the patient to the PACU nurses at 09:45 am. How many minutes of anesthesia time transpired and what is the appropriate anesthesia code?

135 minutes (2 hrs. 15 minutes), 00790-AA-P1, 99100 Rationale: Per Anesthesia Guidelines in the CPT® code book under the subheading Time Reporting: Anesthesia time begins when the anesthesiologist begins to prepare the patient for anesthesia in the operating room (or an equivalent area) and ends when the anesthesiologist is no longer in personal attendance, that is, when the patient may be safely placed under postoperative supervision. In this case the start time is 07:30 am and the end time is 09:45 am equaling a total of 2 hours and 15 minutes or 135 minutes of total anesthesia time. In the CPT® Index look for Anesthesia/Abdomen/Intraperitoneal which directs you to code ranges 00790-00797, 00840-00851. Review the numeric section to determine that the correct code is 00790 as the gallbladder is located behind the liver in the upper abdomen. AA modifier is to indicate the anesthesiologist performed the procedure. The physical status modifier is P1 for a normal healthy patient and qualifying circumstances due to the patient age of 90 is reported with 99100. The correct reporting for this procedure is 00790-AA-P1, 99100 for 135 minutes (2 hrs. 15 minutes). The documentation does not mention Medicare; therefore, 99100 is reported.

A 40-year-old female in good physical health is having a laparoscopic tubal ligation. The anesthesiologist begins to prepare the patient for surgery at 08:30 am. Surgery begins at 09:00 am and ends at 10:00 am. The anesthesiologist releases the patient to recovery nurse at 10:15. What is the total anesthesia time and anesthesia code?

1hr. 45 minutes, 00851 Rationale: Per Anesthesia Guidelines in the CPT® code book under the subheading Time Reporting: Anesthesia time begins when the anesthesiologist begins to prepare the patient for anesthesia in the operating room (or an equivalent area) and ends when the anesthesiologist is no longer in personal attendance, that is, when the patient may be safely placed under postoperative supervision. In this case the anesthesia start time is 08:30 am and the end time is 10:15 am equaling a total of 1 hour and 45 minutes or 105 minutes of total anesthesia time. In the CPT® Index look for Anesthesia/Tubal Ligation which directs you to code 00851. Review the code in the Tabular section to determine that 00851 is the correct code.

A 22-year-old patient who has severe medical problems is placed under general anesthesia by an anesthetist for a service not usually requiring anesthesia. What modifier is appended to the service?

23 Rationale: In the CPT® codebook go to Appendix A - Modifiers. Review the modifiers to determine that modifier 23 is reported to indicate a procedure not usually requiring anesthesia (either none or local) but due to unusual circumstances general anesthesia is necessary.

A 42-year-old patient was admitted to an ASC and began having complications in the OR after the induction of anesthesia. The surgeon immediately discontinued the planned surgery. If the insurance company requires a reported modifier, what modifier best describes the extenuating circumstances for the anesthesiologist?

53 Rationale: In the CPT® code book go to Appendix A and look for modifiers. Review the modifiers to determine that modifier 53 best describes the anesthesia service, which was discontinued prior to the start of surgery. Modifier 73 is only reported by the facility for the use of the facility. Modifier 73 is never reported for physician anesthesia services. The anesthesiologist will report the intended anesthesia code with the start and stop anesthesia time.

Anesthesia start time is reported as 7:14 am, and the surgery began at 7:26 am. The surgery finished at 8:18 am and the patient was turned over to PACU at 8:29 am, which was reported as the ending anesthesia time. What is the anesthesia time reported?

7:14 am to 8:29 am (75 minutes) Rationale: Per Anesthesia Guidelines in the CPT® codebook under the subheading Time Reporting: Anesthesia time begins when the anesthesiologist begins to prepare the patient for anesthesia in the operating room (or an equivalent area) and ends when the anesthesiologist is no longer in personal attendance, that is, when the patient may be safely placed under postoperative supervision. Anesthesia start time (7:14) and anesthesia end time (8:29) calculates as 1 hour and 15 minutes or 75 minutes of total anesthesia time.

Which of the following codes is used to report placement of a flow directed Swan-Ganz catheter?

93503 Rationale: Look in the CPT® Index for Swan-Ganz Catheter/Insertion directing you to 93503 Insertion and placement of flow directed catheter (eg, Swan-Ganz) for monitoring purposes.

An 11-month-old patient presented for emergency surgery to repair a severely broken arm after falling from a third story window. What qualifying circumstance code(s) may be reported in addition to the anesthesia code?

99100, 99140 Rationale: In the CPT® Anesthesia Guidelines under Qualifying Circumstances each of the qualifying circumstances codes identifies a different circumstance, and more than one may be appended when applicable, unless the reported anesthesia code already contains the risk factor. In this case, 99100 is assigned for extreme age of one year or younger and 99140 is assigned for emergency conditions. Note: Qualifying circumstances codes may also be found in the CPT® Medicine subheading Miscellaneous Services/Qualifying Circumstances for Anesthesia.

A 69-year-old Medicare patient with a history of severe cardiopulmonary disease is undergoing surgery with monitored anesthesia care (MAC). Which modifier(s) is used for monitored anesthesia care service?

G9 RATIONALE: Anesthesia care for a Medicare patient who is undergoing MAC and has a history of severe cardiopulmonary disease is reported with modifier G9. The additional modifier QS is not necessary because the description for G9 includes monitored anesthesia care.

What are the three classifications of anesthesia?

General, regional, and monitored anesthesia Care Rationale: An epidural is a type of regional anesthesia. Moderate or conscious sedation is typically provided by the same physician performing the service sedation supports and requires the presence of an independent observer to monitor the patient.

Using your ICD-10-CM Alphabetic Index, look for the diagnosis code for a patient with a postoperative diagnosis of pancreatic mass. Which of the following is the correct diagnosis code?

K86.89 RATIONALE: Look in the ICD-10-CM Alphabetic Index for Mass/pancreas; there is no listing for Mass/pancreas. Refer to Mass/specified organ NEC - see Disease, by site. Look for Disease/pancreas/specified NEC K86.89. The coder should not default to the Table of Neoplasms because the term is Mass, unless otherwise stated. Verify code selection in the Tabular List.

After a routine and uncomplicated appendix surgery, the patient began bleeding postoperatively. What ICD-10-CM coding is reported?

K91.840 Rationale: In the ICD-10-CM Alphabetic Index look for Complication/hemorrhage/postprocedural directing you to see Complication, postprocedural, hemorrhage. In the Alphabetic Index look for Complication/postprocedural/hemorrhage(hematoma)(of)/digestive system/following procedure on digestive system, which directs you to code K91.840. Verify code selection in the Tabular List.

A 77-year-old patient was scheduled for a left total hip replacement due to degenerative joint disease (DJD) and the anesthesiologist documented the DJD as primary. The pre-anesthesia assessment indicates the patient had surgery in 2015 for gastroesophageal reflux disease (GERD). What ICD-10-CM coding is reported?

M16.12 Rationale: The patient's previous surgery (GERD) has no relevance to the anesthesia care provided for the hip surgery and is not reported with a diagnosis code. In the ICD-10-CM Alphabetic Index look for Degeneration/joint disease which states to see Osteoarthritis. Look in the Alphabetic Index for Osteoarthritis/hip or Osteoarthritis/primary/hip which directs you to M16.1-. In the Tabular List confirm the subcategory code. M16.1- indicates that a 5th character is needed to indicate laterality. Report M16.12 for the left hip. There is no indication that this patient has GERD.

A 74-year-old patient is scheduled for a total knee replacement due to degenerative joint disease (DJD) of his left knee. The patient had surgery in 2012 for gastroesophageal reflux disease (GERD). Select the correct diagnosis code(s).

M17.12 Rationale: The patient's previous surgery has no relevance to the anesthesia for the knee surgery. DJD is an abbreviation for degenerative joint disease. Look in the ICD-10-CM Alphabetic Index for Degeneration, degenerative/joint disease which directs you to see Osteoarthritis. Look in the Alphabetic Index for Osteoarthritis/knee M17.1. According to Coding Clinic, Volume 3, Number 4, Fourth Quarter 2016, "When the type of osteoarthritis is not specified, 'primary' is the default." Look at M17.1 in the Tabular List and you will see Primary osteoarthritis of knee NOS. In the Tabular List, a 5th character is needed to report the laterality. Complete code is M17.12 for the left knee.

A patient has foot surgery for a right calcaneal spur. Chronic myocardial ischemia was listed on the pre-anesthesia assessment. What ICD-10-CM coding is reported?

M77.31, I25.9 Rationale: In the ICD-10-CM Alphabetic Index look for Spur, bone/calcaneal, which directs you to M77.3-. Next, in the Alphabetic Index look for Ischemia, ischemic/heart (chronic or with a stated duration of over four weeks), which directs you to I25.9. In the Tabular List confirm the code selection. Code M77.3- indicates that a 5th character is needed to define the laterality of the foot. For a calcaneal spur in the right foot report M77.31. The chronic myocardial ischemia code I25.9 denotes the anesthesia risk and is also reported.

Using your ICD-10-CM Alphabetic Index, what is the diagnosis code for a patient with a postoperative diagnosis of uterus mass?

N85.8 Rationale: In the ICD-10-CM Alphabetic Index look for Mass and you will see there is no subterm for uterus. There is a subterm for specified organ NEC, which states to see Disease, by site. Look in the Alphabetic Index for Disease/uterus/specified NEC, which directs you to code N85.8. Confirm code in the Tabular list. Do not select code D39.8, uncertain behavior, from the Table of Neoplasms because to report this code you need to see a pathology report to support the findings of a neoplasm of uncertain behavior.

A 67-year-old patient is undergoing anesthesia for a re-operation after a coronary bypass two months ago. Which of the following qualifying circumstances may be reported separately?

None of the above RATIONALE: Qualifying circumstances may not be separately reported if the anesthesia code already takes difficulty into consideration.

What ICD-10-CM coding is reported for an uncomplicated incomplete abortion?

O03.4 Rationale: Look in the ICD-10-CM Alphabetic Index for Abortion/incomplete (spontaneous,) which directs you to code O03.4. Verify code selection in the Tabular List. Note that spontaneous is a nonessential modifier to Abortion.

Following labor and delivery, the mother developed acute kidney failure. What ICD-10-CM coding is reported?

O90.4 Rationale: In the ICD-10-CM Alphabetic Index look for Failure/renal/following labor and delivery (acute), which directs you to code O90.4. Verify code selection in the Tabular List. Note: When the failure occurred the patient had already given birth so it should not be coded as a complication during pregnancy.

Which of the following physical status modifiers best describes a normal health patient who is undergoing anesthesia?

P1 RATIONALE: A normal healthy patient is reported with physical status modifier P1. No additional value is recognized.

A young child is having lens surgery related to traumatic glaucoma due to an injury during birth. The anesthesiologist listed congenital glaucoma as the diagnosis. What ICD-10-CM coding is reported?

P15.3 Rationale: In ICD-10-CM Alphabetic Index look for Glaucoma/traumatic/newborn (birth injury), which directs you to code P15.3. ICD-10-CM guideline I.C.16.a.1 indicates that chapter 16 codes may be used throughout the life of the patient if the condition is still present. Note: Congenital is defined as present at birth, such as a birth defect. This injury was caused or acquired during the birth.

What physical status modifier best describes a patient who has a severe systemic disease that is a constant threat to life?

P4 Rationale: Review the Anesthesia Guidelines in the CPT® code book to determine that the physical status modifier P4 is the correct choice. Note: Medicare does not recognize physical status modifiers for additional payment.

The patient had surgery to remove and replace an existing Hickman catheter. The anesthesiologist reported a postoperative diagnosis of a catheter related bloodstream infection (CRBSI). What ICD-10 coding is reported?

T80.211A Rationale: A catheter related bloodstream infection (CRBSI) is a complication. In ICD-10-CM Alphabetic Index look for Infection/due to or resulting from/Hickman catheter/bloodstream, which directs you to code T80.211-. In the Tabular List a 7th character is required to complete the code. Character A is selected for initial encounter.

What is the ICD-10-CM coding for personal history of colonic polyps?

Z86.010 Rationale: In the ICD-10-CM Alphabetic Index look for History/personal (of)/benign neoplasm/colonic polyps, which refers you to code Z86.010. Verify code selection in the Tabular List.