AAPC Chapter 16: Anesthesia

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. 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?

$1,000.00 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® 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. In the scenario above, base units equal three (3) plus two (2) emergency qualifying circumstances units (Base 3 + QC 2 = 5 units). Five (5) time units, in fifteen 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. Ten units (5 + 5 = 10) are then multiplied by the $100 conversion factor (10 X $100 = $1,000.00). Note: Base Unit Values are not separately listed in the CPT®. The American Society of Anesthesiologists (ASA) determines the base units' values for anesthesia codes.

A 72 year-old patient is undergoing a corneal transplant. An anesthesiologist is personally performing monitored anesthesia care. What CPT® code and modifier(s) are reported for anesthesia?

00144-AA-QS, 99100 Rationale: In the HCPCS Level II codebook locate where the HCPCS Level II Modifiers are listed. An anesthesiologist who is personally performing services reports the service with a modifier AA and when the service performed is Monitored Anesthesia Care (MAC) modifier QS is also reported. The modifiers are sequenced first by the anesthesia provider then the MAC modifier which are attached to the appropriate anesthesia code. The Qualifying Circumstances add-on code 99100 is assigned for extreme age of the patient being older than 70 years of age.

A patient presents to the OR for a craniotomy with evacuation of a hematoma. What CPT® code 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® code 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.

Using the CPT® Index, look for anesthesia for a modified radical mastectomy with internal mammary node dissection. Which of the following is the correct anesthesia code?

00406 RATIONALE: Anesthesia/Mastectomy is not listed in the CPT® Index. Look for Anesthesia/Breast to see the code range. Code 00406 is the appropriate anesthesia code for a radical mastectomy with internal mammary node dissection.

CASE 8 Anesthesiologist personally performed case Anesthesia Time: 13:04 to 13:41 Physical Status 3 PREOPERATIVE DIAGNOSIS: RLL Lung Cavity, possible CA of lung POSTOPERATIVE DIAGNOSIS: Right Lower Lobe Lung Carcinoma PROCEDURE: Bronchoscopy ANESTHESIA: Monitored Anesthesia Care 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 are the CPT® and ICD-10-CM Codes reported for the Anesthesiologist? 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 1 lung ventilation utilization.

What is the anesthesia code for a mediastinoscopy utilizing OLV (one lung ventilation)?

00529 Rationale: In the CPT® Index look for Anesthesia/Mediastinoscopy directing you to codes 00528, 00529. These codes represent mediastinoscopy and diagnostic thoracoscopy. Review the codes in the numeric section to determine that 00529 describes the procedure utilizing one lung ventilation (OLV).

A 59 year-old patient is having surgery on the pericardial sac, without use of a pump oxygenator. The perfusionist placed an arterial line. What CPT® code(s) is/are reported for anesthesia?

00560 Rationale: In the CPT® Index look for Anesthesia/Heart which directs you to codes 00560-00567, 00580 or look for Anesthesia/Intrathoracic System which directs you to multiple code ranges. Refer to the numeric section to determine 00560 is the correct code without use of a pump oxygenator. The arterial line placement is NOT reported because the service was not provided by the anesthesiologist.

An 8 month-old has a simple Fontan procedure to repair his tricuspid atresia. During the procedure, the heart-lung machine is used. What are the correct CPT® and ICD-10-CM codes for this anesthesia service?

00561, Q22.4 Rationale: In the CPT® Index look for Anesthesia/Heart which directs you to codes 00560-00567, 00580. Refer to the numeric section to determine that the code 00561 is the correct code for a child less than 1 year of age when a pump oxygenator is used. The parenthetical note under the code states it is not to be used with the qualifying circumstance codes of 99100, 99116 and 99135. In the ICD-10-CM Alphabetic Index look for Atresia/tricuspid valve which refer you to Q22.4. Verify code selection in the Tabular List.

CASE 5 CRNA directly supervised by anesthesiologist (CRNA directly supervised by the Anesthesiologist supports modifier QX.) who is directing two other cases. (Anesthesiologist was directing two cases, this supports the use of modifier QK.) CRNA inserted a separate CVP Swan-Ganz catheter ,(Swan-Ganz is reported separately by the CRNA.) (CVP is reported separately by the CRNA.) and an A-line (A-line (Arterial line) is reported separately by the CRNA.) Patient has a severe systemic disease that is a constant threat to life (Supports modifier P4 for physical status 4.) Anesthesia Time: 11:43 to 15:26 (Time calculates to 3 hours 43 minutes or 223 minutes.) PREOPERATIVE DIAGNOSIS: Multivessel coronary artery disease. POSTOPERATIVE DIAGNOSIS: Coronary artery disease, native artery (Post-operative diagnosis should be used for diagnosis reporting.) 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 (Anesthesia is 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. (Verifies line placement by the Anesthesiology 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 (A bypass machine was used indicating the "pump oxygenator.") 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 d' 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 are the CPT® and ICD-10-CM Codes reported for the Anesthesiologist? What are the CPT® and ICD-10-CM Codes 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 I25.10 223

CASE 4 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 are the CPT® and ICD-10-CM Codes reported for the Anesthesiologist? What is the time reported for this service?

00630-AA-P3 M48.061 206

A 30 year-old patient had anesthesia for an extensive spinal procedure with instrumentation under general anesthesia. The anesthesiologist performed all required steps for medical direction while directing one CRNA. What modifier(s) and CPT® code(s) is/are reported for the anesthesiologist and CRNA services?

00670-QY and 00670-QX Rationale: In the CPT® Index look for Anesthesia/Spinal Instrumentation which directs you to code 00670. Review code in the numeric section. An anesthesiologist who is medically directing care reports their service separately from the CRNA, depending on the number of concurrent cases and the appropriate modifiers for distinction. Because there was only one case, the appropriate modifiers to report are QY for the physician and QX for the CRNA. A QZ modifier would indicate the case was performed by a non-medically directed CRNA. Refer to your HCPCS Level II codebook to verify these anesthesia modifiers.

CASE 9 Anesthesia services personally provided by Anesthesiologist Physical Status 2 Anesthesia Start: 10:03 - Anesthesia Stop: 11:06 PREOPERATIVE DIAGNOSIS: Sternal wound hematoma. POSTOPERATIVE DIAGNOSIS: Complicated upper abdominal wall wound. NAME OF PROCEDURE: Sternal wound exploration and wound vac placement. ANESTHESIA: Monitored Anesthesia Care 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. 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 and the wound was irrigated with antibacterial solution. A wound vac was then placed with the assistance of the wound care nurse. The patient was returned to the PCU in stable condition. What are the CPT ® and ICD-10-CM Codes reported for the Anesthesiologist? What is the time reported for this service?

00700-AA-QS-P2 L76.32 63

What is the anesthesia code for a tubal ligation?

00851 Rationale: In the CPT® Index, look for Anesthesia/Fallopian Tube/Ligation or Anesthesia/Tubal Ligation which directs you to 00851. Review the code in the numeric section to determine that 00851 describes the procedure.

CASE 10 ANES Start: 12:18 ANES End: 13:31 CRNA: John Sleep, CRNA (Non-Medically Directed) ASA Physical Status-III Operative Report Preoperative diagnosis: Stricture of the left ureter, postoperative Postoperative diagnosis: SAME Procedure: 1. Cystoscopy of ileal conduit. 2. Exchange of left nephroureteral catheter. Anesthesia: Monitored anesthesia care. 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 are the CPT® and ICD-10-CM Codes reported for the CRNA? 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 are the CPT® and ICD-10-CM Codes reported for the Anesthesiologist? What are the CPT® and ICD-10-CM Codes 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 2 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 are the CPT® and ICD-10-CM Codes reported for the Anesthesiologist? What is the time reported for this service?

00865-AA-P2; C61; 176

CASE 6 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 are the CPT® and ICD-10-CM Codes reported for the Anesthesiologist? What are the CPT® and ICD-10-CM Codes 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

What is the anesthesia code for a complete removal of the penis, including removal of both the left and right inguinal and iliac lymph nodes?

00936 Rationale: In the CPT® Index look for Anesthesia/Penis which directs you to code range 00932-00938. Review the codes in the numeric section to determine 00936 fully describe the procedure and it is the correct code.

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 code(s) is/are correct for anesthesia?

01270-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 numeric section to determine the correct code is 01270. The qualifying circumstance code 99100 is added to indicate the extreme age of the patient. Physical status modifier P3 indicates the patient has severe systemic disease.

CASE 1 CRNA performed anesthesia (Use Modifier QX to indicate CRNA services with medical direction by a physician.) Anesthesiologist medically directing two cases (Use modifier QK to indicate medical direction of two cases.) Anesthesia Time: 9:30 to 10:06 Physical Status 3 (Physical status 3 - use P3 modifier.) PREOPERATIVE DIAGNOSIS: Cyst on knee POSTOPERATIVE DIAGNOSIS: Baker's Cyst (Use post-operative diagnosis.) PROCEDURE: Excision of Baker's Cyst, knee (Excision is an open procedure and is performed on the knee.) ANESTHESIA: Monitored Anesthesia Care (MAC services require QS modifier.) What are the CPT® and ICD-10-CM Codes reported for the Anesthesiologist? What are the CPT® and ICD-10-CM Codes reported for the CRNA? What is the time reported for this service?

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

CASE 3 Non-medically directed CRNA (CRNA services without medical direction require modifier QZ.) performed anesthesia care and documented intra-operative placement of continuous femoral nerve catheter for post operative pain. (Anesthesia and intraoperative placement of continuous femoral nerve catheter.) Anesthesia Time: 7:18 to 9:10 (Time calculates to 1 hour 52 minutes, or 112 minutes.) Physical Status 3 (Physical status 3 requires P3 modifier.) PREOPERATIVE DIAGNOSIS: Left Knee Osteoarthritis POSTOPERATIVE DIAGNOSIS: Left Knee Osteoarthritis, localized primary, (Primary diagnosis is specified as Left Knee Osteoarthritis, localized, primary.) Acute post-operative pain (Diagnosis of Acute post-operative pain gives medical necessity for the intra-operative placement of continuous femoral nerve catheter.) PROCEDURE: Total Knee Arthroplasty (The procedure is total knee arthroplasty NOT Arthroscopy, which carries a lower base value.) ANESTHESIA: General anesthesia (Anesthesia provided is general.) provided for surgery, Surgeon requested post-operative pain management via continuous femoral catheter What are the CPT® and ICD-10-CM Codes reported for the CRNA? What is the time reported for this service?

01402-QZ-P3, 64448-59 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 appropriate code for a patient who had regional block anesthesia provided for carpal tunnel surgery?

01810 Rationale: In this example it is important to understand the type of anesthesia provided will not determine the anesthesia code. In the CPT® Index look for Anesthesia/Arm/Lower which directs you to code ranges 00400, 01810-01820, 01830-01860. Review the codes in the numeric section to determine code 01810 is correct. The coder must know that carpal tunnel surgery refers to the median nerve in the wrist. Hint -Try looking up the surgical code for clues to the anatomical area when necessary for assistance.

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

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

Report the appropriate anesthesia code for an obstetric patient who had a planned general anesthesia for cesarean hysterectomy.

01963 Rationale: Use the CPT® Index look for Anesthesia/Hysterectomy/Cesarean which directs you to 01963, 01969. Review the codes in the numeric section to determine that code 01963 is the appropriate code. Note: Code 01969 is an add-on code and cannot be coded without a primary procedure code.

What anesthesia code(s) should be assigned for an obstetric patient who had neuraxial labor analgesia provided by the anesthesiologist when the delivery was expected to be a normal vaginal delivery but the obstetrician performed a cesarean delivery when the fetal heart rate dropped?

01967, 01968 Rationale: In the CPT® Index under Anesthesia/Neuraxial/Labor which directs you to code range 01967-01969. Review the codes in the numeric section to determine that codes 01967, 01968 are the correct codes. Code 01967 describes the initial service without the cesarean delivery. Code 01968 is an add-on code which adds the cesarean delivery. Add-on codes must be coded in conjunction with the primary code and cannot be coded alone. The correct codes are 01967, 01968.

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.

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 1015. What is the total anesthesia time and anesthesia code?

1hr. 45 minutes, 00851 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. In this case the 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 numeric section to determine that 00851 is the correct code.

Mrs. Jones is a 90 year-old female having laparoscopic surgery on her gallbladder. 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?

2 hrs. 15 minutes, 00790-P1, 99100 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. 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 145 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. The physical status modifier is P1 for a normal healthy patient and the Qualifying Circumstances due to the patient age of 90 should be coded to 99100. The correct reporting for this procedure is 00790-P1, 99100 for 2 hrs. 15 minutes.

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 would be 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.

An anesthesiologist was called to the emergency room to intubate a patient with respiratory difficulty. Which procedure code is reported?

31500 RATIONALE: The anesthesiologist is not providing an intubation for a patient undergoing anesthesia. An emergency intubation is correctly reported as 31500. Look in the CPT® Index for Intubation/Endotracheal Tube.

A 5 year-old patient is experiencing atrial fibrillation with rapid ventricular rate. The anesthesia department is called to insert a nontunneled central venous (CV) catheter. What CPT® code is reported?

36556 Rationale: The coder should note that this is NOT a general anesthesia service so a code from the Anesthesia Section of CPT® would not be appropriate. In the CPT® Index look for Catheterization/Central Venous which states see Central Venous Catheter Placement. Look for Central Venous Catheter Placement/Insertion/Central/Non-tunneled which directs you to codes 36555, 36556. Review the numeric section to determine the correct code is 36556 for the 5 year-old patient. Note: The coder should note the type of insertion and the age of the patient to make the correct choice of codes.

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.

An anesthesiologist is medically supervising five cases at the same time. Which modifier(s) report(s) the anesthesiologist and CRNA services?

AD and QX RATIONALE: An anesthesiologist who is medically supervising reports the service separately from the CRNA. Supervision of more than four concurrent anesthesia procedures is reported with modifier AD. The CRNA reports with modifier QX.

What is the correct ICD-10-CM diagnosis code for a patient with a postoperative diagnosis of a malignant pancreatic mass?

C25.9 Rationale: In the ICD-10-CM Table of Neoplasms look for Neoplasm, neoplastic/pancreas and select from the Malignant Primary column which directs you to C25.9. Verify code selection in the Tabular List. Because the mass is documented as malignant, the malignant cancer code is reported. Please refer to the notes at the beginning of the Neoplasm Table.

Using your ICD-10-CM Alphabetic Index, look for the diagnosis code for a patient with a preoperative diagnosis of abdominal pain, right lower quadrant and a postoperative diagnosis of uterine fibroids. Which of the following is the correct diagnosis code?

D25.9 RATIONALE: The preoperative diagnosis is disregarded because a more definitive diagnosis is determined following surgery. Look in the ICD-10-CM Alphabetic Index for Fibroid/uterus D25.9. Verify code selection in the Tabular List.

What ICD-10-CM code is reported for a type 2 diabetic cataract on the left eye?

E11.36 Rationale: Look in the ICD-10-CM Alphabetic Index for Diabetes, diabetic/type 2/with/cataract which directs you to code E11.36. Verify code selection in the Tabular List. Note that this is a combination code that define the disease and complication with one code.

A patient with diabetic peripheral circulatory disorder is having a lower leg amputation due to gangrene. What ICD-10-CM code(s) is/are reported?

E11.52 Rationale: In the ICD-10-CM Alphabetic Index look for Diabetes, diabetic (mellitus) (sugar)/type 2/with/peripheral angiopathy/with gangrene which directs you to code E11.52. This is a combination code that reports both the diabetic status of the patient and the complication due to the diabetic state. Note: ICD-10-CM guideline I.C.1.C.4.a.2 indicates that if the diabetic type is not documented the coder should default to type 2. Verify code selection in the Tabular List.

A 74 year-old patient is undergoing surgery under monitored anesthesia care (MAC). The surgeon has determined the procedure will be markedly invasive. What modifier(s) is/are appropriate for Medicare?

G8 Rationale: In the HCPCS Level II codebook locate where the HCPCS Level II Modifiers are listed. A patient who is undergoing monitored anesthesia care (MAC) for a deep complex, complicated or markedly invasive surgical procedure may be reported with modifier G8. The additional modifier QS is not necessary because the description for G8 includes monitored anesthesia care.

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.

A patient is scheduled for monitored anesthesia care (MAC) to remove an eyelid cyst. Normally the surgeon provides moderate sedation for the removal; however, this patient has a history of failed moderate sedation. Select the correct diagnosis code(s).

H02.829, Z92.83 RATIONALE: The reason for the anesthesiologist's involvement for the monitored anesthesia care (MAC) in the surgery is the patient's history of failed moderate sedation. The eye cyst is first-listed as it is the medical necessity for the surgery and Z92.83 is an additional diagnosis to explain the need for anesthesia care. In the ICD-10-CM Alphabetic Index, look for Cyst/eyelid (sebaceous) directing you to H02.829. Next, look in the Alphabetic Index for History/personal (of)/failed conscious sedation directing you to Z92.83. Verify code selection in the Tabular List.

A patient undergoes heart surgery for angina decubitus and coronary artery disease (CAD). What ICD-10-CM code is reported?

I25.118 Rationale: In the ICD-10-CM Alphabetic Index look for Disease/coronary (artery) which states see Disease/heart/ischemic/atherosclerotic (of) with angina pectoris which directs you to see Arteriosclerosis, coronary (artery). Look for Arteriosclerosis/coronary (artery)/native vessel/with/angina/specified type NEC which directs you to I25.118. Verify code selection in the Tabular List.

Using your ICD-10-CM codebook look for the diagnosis code for a patient with a preoperative diagnosis of abdominal pain, right lower quadrant and a postoperative diagnosis of acute appendicitis with peritoneal abscess. What ICD-10-CM code is reported?

K35.3 Rationale: The preoperative diagnosis of abdominal pain in the right lower quadrant is not reported because there is definitive diagnosis listed post-operatively. The postoperative diagnosis specifies acute appendicitis with peritoneal abscess. Look in the ICD-10-CM Alphabetic Index for Appendicitis/with/peritoneal abscess which directs you to K35.3. Verify code selection in the Tabular List.

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

K91.840 Rationale: In the ICD-10-CM Alphabetic Index look for Complication/hemorrhage/postprocedural directs you to see Complication, postprocedural hemorrhage. 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 patient has foot surgery for a right calcaneal spur. Chronic myocardial ischemia was listed on the pre-anesthesia assessment. What ICD-10-CM code(s) is/are 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 under Ischemia, ischemic/heart (chronic or with a stated duration of over 4 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. Calcaneal spur in the right foot report M77.31, for the foot surgery. 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 Alphabetic Index look for Mass, 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 for Disease/uterus/specified NEC which directs you to code N85.8. Confirm code in the Tabular list. You will not select code D39.8, uncertain behavior from the Table of Neoplasms because to report this code we 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 code 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 code 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 code 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® codebook to determine that the Physical Status modifier P4 is the correct choice. Note: Medicare does not recognize physical status modifiers for additional payment.

An anesthesiologist is medically supervising six cases. What modifier is reported for the CRNA's medically directed service?

QX Rationale: In the HCPCS Level II codebook locate where the HCPCS Level II Modifiers are listed. A CRNA service under medical direction is coded with modifier QX. Reporting modifier QZ indicates the anesthesia was performed by non-medically directed CRNA and results in overpayment for the anesthesia service provided. The other two modifier selections are only reported for physician services. Modifier QX is assigned because there is no way the CRNA knows medical direction changed to medical supervision.

A CRNA is personally performing a case with medical direction from an anesthesiologist. What modifier is appropriately reported for the CRNA services?

QX Rationale: In the HCPCS Level II codebook locate where the HCPCS Level II Modifiers are listed. A CRNA with medical direction from an anesthesiologist is appropriately reported with modifier QX. Any time the CRNA is working with medical direction, the anesthesia procedure is reported with QX. The anesthesiologist reports QY if only directing one CRNA and QK if directing 2 to 4 CRNAs.

What modifier is used for medically-directed CRNA services?

QX Rationale: In the HCPCS Level II codebook look for where the modifiers are listed and refer to modifier QX. QX is the correct modifier for CRNA services when medically directed by a physician.

A CRNA is personally performing a case, without medical direction from an anesthesiologist. Which modifier reports the CRNA services?

QZ RATIONALE: A CRNA without medical direction is reported with QZ modifier.

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-CM code(s) is/are 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 ICD-10-CM code is reported for a reaction to anesthesia, initial encounter?

T88.59XA Rationale: Look in the ICD-10-CM Alphabetic Index for Anesthesia, anesthetic/complication or reaction NEC (see also Complications, anesthesia) which directs you to code T88.59-. The Tabular List indicates that code T88.59- requires a 7th character with no 6th character listing. Insert the placeholder X as the 6th character. Select the 7th character A for initial encounter.