AAPC - Chapter 16 Practical Applications
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?
00140-QK-QS-P3 M71.20 001400-QX-QS-P3 M71.20 36
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
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 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
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
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? CPT® code(s): [a] ICD-10-CM code(s): [b] 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
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