anesthesia list – Flashcards
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Define types of anesthesia
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Anesthesia Chapter Topics Types of Anesthesia Anesthesia Section Format Formula for Anesthesia Payment Concurrent Modifiers Unlisted Anesthesia Code Other Reporting Learning Objectives After completing this chapter you should be able to 1
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Explain the format of the Anesthesia section and subsections
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Understand the anesthesia formula
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Identify other reporting issues
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Demonstrate ability to report anesthesia services
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TYPES OF ANESTHESIA The Anesthesia section is a specialized section that is used by an anesthesiologist, anesthetist, or other physician to report the provision of anesthesia services, usually during surgery
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Anesthesia means induction or administration of a drug to obtain partial or complete loss of sensation
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Analgesia (absence of pain) is achieved so that a patient may have surgery or a procedure performed without pain
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Types of anesthesia may be general, regional, local, or monitored anesthesia care (MAC)
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Moderate (conscious) sedation is not reported with anesthesia codes but rather is reported with Medicine codes
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Local anesthesia is usually administered by the surgeon
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The practice of anesthesiology is not limited to administration of anesthesia for the surgical patient
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The management of procedures for rendering a patient insensible to pain and emotional stress during surgical, obstetrical, and other diagnostic and therapeutic procedures
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The American Society of Anesthesiologists (ASA) defines the practice of anesthesiology as dealing with but not limited to the following: n
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The evaluation and management of essential physiologic functions under the stress of anesthetic and surgical manipulations
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The clinical management of the patient unconscious from whatever cause
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The evaluation and management of acute or chronic pain
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The management of problems in cardiac and respiratory resuscitation
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The application of specific methods of respiratory therapy
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The clinical management of various fluid, electrolyte, and metabolic disturbances
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* Take a moment and consult a good medical dictionary under the entry "anesthesia
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" You will find that in addition to the definition of the term anesthesia, a wide variety of types of anesthesia are defined
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Some types of anesthesia are named for the site of the anesthesia administration, such as sacral, lumbar, and caudal
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Other types of anesthesia are named for the category of anesthesia, such as freezing (frost) for cryoanesthesia
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Some of the more commonly used anesthesia terms are endotracheal, epidural, regional, and patient-controlled analgesia
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Endotracheal anesthesia is accomplished by insertion of a tube into the nose or mouth, and passing the tube into the trachea for ventilation, as illustrated in Fig
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16-1
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Epidural anesthesia is the injection of an anesthetic agent into the epidural spaces between the vertebrae, also known as peridural, or epidural block
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Spinal or intraspinal anesthesia refers to anesthesia produced by an injection of local anesthetic into the subarachnoid space around the spinal cord
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General anesthesia is a state of unconsciousness that is accomplished by the use of a drug or combination of drugs administered intramuscularly, rectally, intravenously, or by inhalation
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Regional anesthesia interrupts the sensory nerve conductivity in a region of the body and is produced by a field block (forming a wall of anesthesia around the site by means of local injections) or nerve block (injection of the area close to the site)
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Nerve block is also known as block, block anesthesia, or conduction anesthesia
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Although not a type of anesthesia, a procedure used by anesthesiologists for treatment of a postdural puncture headache is a blood patch, also known asan epidural blood patch (EBP)
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A blood patch procedure is when a cerebrospinal fluid leak is closed by means of an injection of the patient's blood into the epidural space at or near the area of the dural puncture that was accessed during spinal anesthesia
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Local anesthesia can be accomplished by means of application of an anesthetic agent (such as lidocaine) placed directly on the area involved (topical anesthesia) or local infiltration through subcutaneous injection of an anesthetic agent
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Lidocaine can be subcutaneously injected, as illustrated in Fig
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Patient-controlled analgesia (PCA) is a system that allows the patient to administer an analgesic drug such as morphine to control pain
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A device is attached to a pump holding the drug and the patient can depress a handheld button to administer a dose of the drug (Fig
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In this way, the patient can control the amount of the drug and the frequency of administration
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PCA is considered a hospital service and not generally reported by a physician
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Refer to individual payer guidelines for instructions to report PCA management
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Monitored Anesthesia Care (MAC) MAC is provided by an anesthesiologist or CRNA
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Each type of anesthesia will be covered in depth, but generally speaking, the types of anesthesia are: n
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The patient is monitored, and if necessary, sedation is provided
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even general anesthesia
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General anesthesia Used for cases that requires deep sedation, such as open heart surgery or complicated abdominal surgery
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The patient is usually intubated
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The patient is in a deep state of sedation and is not arousable or able to communicate or follow commands
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Several different types of medication may be used during general anesthesia, including drugs for analgesia (pain relief), sedation, amnesiacs (to lessen awareness), and paralytics for muscle relaxation to prevent movement or reflexive action by the patient during procedures
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Regional anesthesia Regional anesthesia uses injection to target the nerves of the area being treated
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Spinal and epidural anesthesia Spinal anesthesia is administered into the cerebral spinal fluid or epidural area of the spine that corresponds with the area being treated
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Spinals are generally used for procedures below the waist
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Epidural catheters are often placed to facilitate administration of medication into the spinal region
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Moderate (Conscious) Sedation Moderate or conscious sedation is a type of sedation that can be provided by a surgeon or the surgeon's staff while the surgeon is performing a procedure
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it provides a decreased level of consciousness that does not put the patient completely to sleep
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This level of consciousness allows the patient to breathe without assistance and to respond to stimulation and verbal commands
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A trained observer must be present when moderate sedation services are provided by the same physician performing the therapeutic or diagnostic service in order to assist the physician in monitoring the patient
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The codes to report conscious sedation are located in the Medicine section (99143-99150), not in the Anesthesia section
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Codes 99143-99145 report the moderate sedation services when the service is provided by the same physician performing the diagnostic or therapeutic service and requires the presence of an independent trained observer
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The codes are divided based on the patient's age of under or over 5 years of age and the duration of the service
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Codes 99148-99150 report moderate sedation services when the anesthesia service is provided by a physician other than the health care professional performing the service
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These codes are divided based on the patient's age of under or over 5 years of age and the duration of the service
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Bundled into these codes is the assessment of the patient, establishment of intravenous access, administration of the sedation agent, sedation maintenance, monitoring of patient vital signs, and recovery from anesthesia
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The code descriptions for the Moderate (Conscious) Sedation codes include the term "intraservice time
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" Intraservice time begins with the administration of the sedation agent, requires continuous face-to-face attendance by the physician, and ends when the personal contact by the physician ends
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The time the physician spends with the patient in assessment of the patient prior to administration of the sedation and the time in recovery is not included in the intraservice time
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CODING SHOT Moderate (conscious) sedation codes are only reported when the physician performing the procedure administers the sedation and an independent trained observer assists
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CAUTION Do not confuse conscious sedation with monitored anesthesia care
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Conscious sedation is administered by the surgeon or another physician
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MAC is provided by an anesthesiologist or CRNA
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Moderate or conscious sedation methods are much less invasive than anesthesia services that provide the complete loss of consciousness
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For example, for a colonoscopy, a physician could administer an intravenous sedation, such as meperidine (Demerol), morphine, or diazepam (Valium)
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The patient would be monitored closely as the medication is administered so that the appropriate level of sedation is reached
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After the procedure, the physician may administer a drug intravenously to reverse the effects of the sedation
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The patient would have this procedure in an outpatient setting and be able to go home after the procedure
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Moderate sedation is included in many CPT codes and, as such, is not reported separately
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) is displayed to the left of the codes in the CPT manual that include the moderate/conscious sedation bundled into the code
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The bullseye (
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For example, the codes in the 33206-33208 range report insertion of a new or replacement of a permanent pacemaker and include moderate sedation
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Appendix G in the CPT manual lists the codes that include moderate sedation
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Example Therapeutic reason: 01925 Anesthesia for therapeutic interventional radiological procedures involving the arterial system
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carotid and coronary Diagnostic reason: 01922 Anesthesia for non-invasive imaging or radiation therapy ANESTHESIA SECTION FORMAT Most anesthesia codes are divided first by anatomic site and then by specific type of procedure, as shown in Fig
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The last four subsections in Anesthesia—Radiologic Procedures (01916-01936), Burn Excisions or Debridement (01951-01953), Obstetric (01958-01969), and Other Procedures (01990-01999)—are not organized by anatomic division
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The CPT codes in the Radiologic Procedures subsection report anesthesia service when radiologic services are provided to the patient for diagnostic or therapeutic reasons
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Anesthesiologist n Certified registered nurse anesthetist (CRNA) n Anesthesiologist's assistant (who may not work without oversight of anesthesiologist) n Resident (cannot bill if the case is performed without the participation of another anesthesia provider) n Student registered nurse anesthetist (billing is based on specific rules for each payer depending on the payer's definition of medical direction) FORMULA FOR ANESTHESIA PAYMENT When an anesthesiologist provides an anesthesia service to a patient, the preoperative, intraoperative/intraservice (care during surgery), and postoperative care are all included in the CPT code
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Anesthesia providers may be a(n): n
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These services include the usual preoperative and postoperative visits (on day of surgery) to the patient by the anesthesiologist
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the routine intraoperative care, such as administration of fluids and/or blood
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and the usual monitoring services
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The care also includes the patient's history taken by the anesthesiologist, ventilation establishment, and administration of preoperative and postoperative medications
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Monitoring services include blood pressure, temperature, arterial oxygen levels (oximetry), exhalation of carbon dioxide (capnography), and spectrometry (blood analysis)
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The intraoperative care includes intubation to administer anesthesia
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Postoperative care usually includes pain management
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Some pain management is reported separately, e
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, spinal injection for significant postoperative pain
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If the anesthesiologist provides care that is unusual or beyond that which would usually be provided, these services can be reported in addition to the basic anesthesia service
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For example, if the patient requires intraoperative cardiac monitoring, the anesthesiologist may insert a Swan-Ganz catheter, as illustrated in Fig
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A Swan-Ganz catheter is not a normal service provided during a surgery, so it could be reported using a code from the Medicine section for placement of a flow-directed catheter (93503)
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Some payers will require modifier -59 (distinct procedural service) be appended to the catheter code if another central line is also placed
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The time necessary to insert the catheter is not counted in the anesthesia time because the service of the insertion is reported separately and is considered a surgical procedure
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Reporting the insertion separately and also adding the insertion time to the anesthesia service would result in double payment for the insertion service
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What makes anesthesia coding different from any other coding is the way in which anesthesia services are billed
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There is a standard formula for payment of anesthesia services that is, for the most part, nationally accepted
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The formula is base units 1 time units 1 modifying units (B 1 T 1 M) 3 conversion factor
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Let's look at each of these elements in more detail
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Another tool is the ASA CROSSWALK book from the American Society of Anesthesiologists and it provides anesthesia coders with a comprehensive list of CPT codes that link to the corresponding anesthesia code(s)
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This book also lists the base value of each anesthesia service
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CPT codes are located in the crosswalk book enabling the anesthesia coder to select the service with the highest base value for submission
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The book also lists alternative codes, allowing the anesthesia coder to make the most specific selection
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The anesthesia crosswalk book is updated by the ASA annually
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B Is for Base Unit The ASA publishes a Relative Value GuideTM (RVG), which contains codes for anesthesia services and the base unit value for each anesthesia code
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The CPT manual also contains these anesthesia service codes in the Anesthesia section
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Italicized comments appear in the American Society of Anesthesiologists' Relative Value GuideTM to clarify code assignment, as illustrated in Fig
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These italicized comments are not part of the CPT manual
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CODING SHOT Anesthesia is paid based on: Base units + Time units + Modifying units (if allowed) x conversion factor CMS's Base Units
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The RVG is not a fee schedule (a list of charges for services) but instead compares anesthesia services with each other
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For example, anesthesia services provided for a biopsy of a sinus are less complicated than services provided for a radical sinus surgery
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A team of physicians with expertise in anesthesiology developed the comparisons and assigned numerical values to each service, termed the base unit value (Fig
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Annually, CMS also publishes a list of the base unit values for the codes, as illustrated in Fig
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CMS RULES For Medicare, anesthesia service involving multiple procedures is reported with the CPT anesthesia code for the procedure with the highest base unit value
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The actual total time for all procedures is reported
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Only one anesthesia code can be reported
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There is an exception for the add-on codes for burn excision or debridement (01953) and obstetrics (01968, 01969)
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The pricing for add-on anesthesia codes is different than other payers because only the base unit value of the add-on code is allowed and all anesthesia time is reported with the primary anesthesia code
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There is an exception to this rule when reporting obstetrical anesthesia, as both the base unit value and time units for the primary and add-on, obstetrical codes are reported
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CMS RULES For Medicare, time units are computed by dividing the reported actual anesthesia service time by 15 minutes and then rounding to one decimal place
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No time units are reported for anesthesia CPT codes 01953 and 01996
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Medicare reimburses for anesthesia services based on a combination of time and base units multiplied by a geographic-area-specific conversion factor
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The CMS's base unit value is accepted as the standard in the United States for most third-party payers
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One coding circumstance unique to anesthesia coding occurs when multiple surgical procedures are performed during the same session
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In this case, only the procedure with the highest base unit value is assigned
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For example, if during the same surgical procedure session a clavicle biopsy (base unit value of 3) and a radical mastectomy (base unit value of 5) are performed, the base unit value for both procedures becomes 5
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The anesthesia service is then reported with only the code for the higher base unit value
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T Is for Time Anesthesia services are provided based on the time during which the anesthesia was administered and calculated, in total minutes
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The timing is started when the anesthesiologist begins preparing the patient to receive anesthesia and is in constant attendance with the patient, continues through the procedure, and ends when the patient is turned over to the post-anesthesia caregivers
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The minutes during which anesthesia was administered are recorded in the patient record
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Carriers independently determine the amount of time that is considered a unit
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Often, 15 minutes equal a unit, but for some carriers, 1, 10, or 30 minutes equals a unit
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The start time on the anesthesia record should match the time reported on the claim form
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The recorded time on all records must be the same: Anesthesia record CRNA, anesthesiologist, or resident billing slip Time on all documents submitted to insurance company When completing the Medicare claim, always record the actual time—that is, the time the anesthesia provider spent personally attending the patient
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Many private payers also require actual time, so it is necessary to verify time submission requirements with each payer
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Private payers may or may not reimburse CRNA services, or they may require these services be reported under the supervising anesthesiologist's name and NPI (National Provider Identification) number
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You must verify the method for submission for each payer
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When preparing the claim, always record the actual time that indicates the ending time of personal attendance
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The time is illustrated in Fig
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The stop time is when the patient can be safely turned over to a non-anesthesia provider
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This generally does not occur in the operating room
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The start time on the anesthesia record should match the time reported on the claim form and indicate the beginning time of the service
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16-9, B illustrates the medical document that contains the pre-anesthesia evaluation that the provider completes prior to the start of surgery
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There are two base-modifying factors: qualifying circumstances codes and physical status modifiers
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Qualifying Circumstances
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At times, anesthesia is provided in situations that make the administration of the anesthesia more difficult
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These types of cases include those that are performed in emergency situations and those dealing with patients of extreme age
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They also include services performed during the use of controlled hypotension or the use of total body hypothermia (refer to Fig
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The Qualifying Circumstances codes begin with 99 and are considered adjunct codes, which means that the codes can never be reported alone but must be used in addition to another code to provide additional information
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A Qualifying Circumstances code is reported in addition to the anesthesia procedure code
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Qualifying Circumstances codes are located in two places in the CPT manual: the Medicine section and the Anesthesia section Guidelines
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In both locations the plus symbol is located next to the codes (99100-99140), indicating their status as add-on codes
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When used, the Qualifying Circumstances code is reported in addition to the primary anesthesia procedure code
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Anesthesia for procedures on eye
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For example, if anesthesia was provided for an 80-year-old patient during a corrective lens procedure, the reporting would be: 00142
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Anesthesia for 80-year-old patient The RVG lists the Qualifying Circumstances codes along with the relative value for each cod
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lens surgery 99100
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The CPT index lists the Qualifying Circumstances codes under Anesthesia, Special Circumstances
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Physical Status Modifiers
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The second type of modifying unit used in the Anesthesia section is the physical status modifier (refer to Fig
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These modifiers indicate the patient's condition at the time anesthesia was administered and identify the level of complexity of the services provided to the patient
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For instance, anesthesia service to a gravely ill patient is much more complex than the same type of service to a normal, healthy patient
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The physical status modifier is not assigned by the coder but is determined by the anesthesiologist and documented in the anesthesia record
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The physical status modifier begins with the letter "P" and contains a number from 1 to 6 (see Fig
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Note that the relative value for P1, P2, and P6 is zero because these conditions are considered not to affect the service provided
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A physical status modifier is used after the five-digit CPT code and is illustrated in Fig
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Summing It Up! Most health care facilities have software that automatically performs the conversion calculations based on the various conversion factors and unit designations
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However, you still need to understand the process used to convert the anesthesia formula into the anesthesia payment
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Let's put the elements of the equation to practical use by applying the equation (B 1 T 1 M) to a case
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An 84-year-old female (qualifying circumstance for extreme age, value 1) with severe hypertension (value of 1) has a 4-cm malignant lesion removed from her right knee (base value of 3)
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The total time of anesthesia service was 60 minutes, and the carrier indicates a unit is 15 minutes (4 units)
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The anesthesiologist recorded that the patient's physical status at the time of the procedure was P3 for a severe systemic disease (relative value of 1), for the severe hypertension
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base procedure value 4 time units 2 modifiers: physical status = 1
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3
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total units Conversion Factor
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extreme age = 1 9
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A conversion factor is the dollar value of each unit
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Each third-party payer issues a list of conversion factors
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The lists vary with geographic location because the cost of practicing medicine varies from one region to another
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16-13 shows an example of a third-party payer's (CMS) anesthesia conversion factors
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Note that North Dakota is $20
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61 per unit and Manhattan, NY, is $23
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56 per unit, as it is less expensive to provide anesthesia services in Grand Forks, ND, than it is to provide the same services in Manhattan, NY
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The conversion factor for the locale is multiplied by the number of units for the procedure
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For example, the previous case had 9 units
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If the anesthesiologist was located in Manhattan, NY, and the conversion factor is $23
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56, the total for the procedure would be $212
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04 (9 3 $23
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56)
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If the same services were provided in North Dakota, with the conversion factor of $20
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61, the total for the procedure would be $185
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49 (9 3 $20
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When multiple surgical procedures are performed during a single anesthetic administration, the anesthesia code that represents the highest base value unit procedure is reported
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Multiple Procedures n
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The time reported is the combined total for all procedures
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Assign the code for procedure of highest base value unit
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n
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Indicate cumulative start/stop time for all surgical procedures performed
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n
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Anesthesia time for a medically necessary surgical procedure performed during the same intra-operative session as a cosmetic procedure should be split and reported separately
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CODING SHOT According to Medicare rules, modifier -50 would not be used on anesthesia CPT codes
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It would be used on anesthesia surgical procedures, performed by anesthesiologists, such as femoral continuous blocks for pain management for bilateral knee replacement (64448-59-50), in addition to the ASA code or anesthesia CPT code
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CONCURRENT MODIFIERS Some third-party payers require additional modifiers to indicate how many cases an anesthesiologist was performing or directing at one time
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Certified registered nurse anesthetists (CRNAs) may administer anesthesia to patients under the direction of a licensed physician, or they may work independently
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An anesthesiologist may medically direct up to four cases at the same time (concurrently)
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If a physician directs more than four cases, it is referred to as medical supervision
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Medical direction means the directing anesthesiologist is present at the induction and emergence from anesthesia, for all key portions of the procedure, and is immediately available in case of an emergency
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The CRNA would be with the patient the entire time
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CMS RULES When medical direction occurs, certain documentation must be submitted for services for Medicare patients
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The documentation must support that certain services were personally performed by the physician
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These include: 1
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Pre-anesthesia examination and evaluation 2
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Prescription of an anesthesia plan 3
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Personally participates in the most demanding procedures in the anesthesia plan, including induction and emergence 4
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Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist 5
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Monitors the course of anesthesia administration at frequent intervals 6
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Remains physically present and available for immediate diagnosis and treatment of emergencies 7
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Provides indicated post-anesthesia care (42 C
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R
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Anesthesia services performed personally by an anesthesiologist -AD Medical supervision by a physician
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110 Conditions for Payment: Medically directed anesthesia services) Additional modifiers that define the types of providers involved in anesthesia are: -AA
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Monitored anesthesia care (MAC) for deep, complex, complicated, or markedly invasive surgical procedure -G9 Monitored anesthesia care for patient who has a history of severe cardiopulmonary condition -QK Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals -QS Monitored anesthesia care service -QX Certified registered nurse anesthetist (CRNA) service, with medical direction by a physician -QY Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist -QZ CRNA service, without medical direction by a physician These modifiers are not CPT modifiers but HCPCS modifiers and further define the anesthesia services provided
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more than 4 concurrent anesthesia procedures -G8
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Anesthesia modifiers are always placed first after the CPT anesthesia code
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These anesthesia modifiers are pricing modifiers and are listed first to assure correct reimbursement
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In the Anesthesia section, an unlisted procedure code is available and is located under the Other Procedures subsection in the Anesthesia section
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UNLISTED ANESTHESIA CODE
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When there is no CPT code to indicate the anesthesia services, the unlisted Anesthesia code (01999) may be reported
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OTHER REPORTING Return to Operating Room If a patient is returned to the operating room on the same day for the same or a related procedure, and the same individual is performing the second procedure, report the service with modifier -76
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For example, the anesthesiologist provides the service for an upper gastrointestinal endoscopic procedure and reports the service 00740-AA
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Later that day, the patient is returned for a lower intestinal endoscopic procedure
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The second service would be reported 00810-AA-76
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If that second procedure was performed by another anesthesiologist, the second service would be reported 00810-AA-77
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Pre-Anesthetic Examination If the pre-anesthetic examination was provided by an anesthesiologist for a patient who did not undergo surgery, the E/M service would be reported for consideration for reimbursement
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Step by step book completed
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Introduction To CPT Coding Book II Chapter Objectives Describe the types of anesthesia Understand the anesthesia guidelines for coding anesthesia services and any additional procedures or services provided Explain anesthesia modifiers Review the use of codes for reporting qualifying circumstances for anesthesia services Understand basic anesthesia administration services Introduction Achieving the basic understanding of anesthesia administration services used by an anesthesiologist, anesthetist, or under the responsible supervision of a physician is essential to coding anesthesia services correctly
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Although this section may seem straightforward, it is critical to develop an understanding of the anesthesia guidelines, the anesthesia modifiers, and qualifying circumstances codes
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This chapter will provide an overview of the Anesthesia codes (00100-01999) of the CPT codebook
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Guidelines for Reporting Basic Anesthesia Administration Services The anesthesia guidelines define items that are necessary to appropriately interpret and report the procedures and services contained in this section
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The guidelines also provide explanations regarding terms that apply only to this particular section
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For example, in the anesthesia guidelines, a discussion of reporting time is included
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Anesthesia time begins when the anesthesiologist begins to prepare the patient for induction of anesthesia in the operating room (or in an equivalent area)
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The time continues through the procedure and ends when the anesthesiologist is no longer in personal attendance, that is, when the patient may be safely placed under postoperative supervision
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Basic anesthesia administration services are services provided by or under the responsible supervision of a physician
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These services include, but are not limited to, the following: Routine preoperative and postoperative visits to evaluate the patient for the planned anesthesia Anesthesia care during the procedure and monitoring of the patient's postsurgery recovery from anesthesia Administration of fluids and/or blood during the period for anesthesia care Interpretation of noninvasive monitoring such as electrocardiography (ECG), body temperature, blood pressure, oximetry (blood oxygen concentration), capnography (blood carbon dioxide concentration), and mass spectrometry
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Invasive forms of monitoring (such as intra-arterial, central venous, pulmonary artery catheters, and transesophageal echocardiography) are not included in basic anesthesia administration services
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When these procedures are performed, they should be reported separately according to standard CPT coding guidelines applicable to the given code and the respective section in the CPT codebook in which they are listed
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Generally, a single code is reported for anesthesia administration, whether the operating physician performs one or multiple procedures
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When multiple procedures are performed during a single anesthetic administration, usually only the anesthesia procedure code for the most complex service and the total time for all procedures are reported
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However, anesthesia add-on codes are an exception
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Codes 01953, 01968, and 01969 are anesthesia add-on procedures, which are reported in addition to the primary anesthesia code
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• Moderate (conscious) sedation • Anesthesia • General anesthesia • Regional anesthesia • Local anesthesia • Monitored Anesthesia Care (MAC) • Anesthesia modifiers • Physical status modifiers A patient having total knee replacement surgery may receive a regional anesthetic and a postoperative pain management agent through the same epidural catheter, in which case the only code reported would be 01402
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A patient undergoing a thoracotomy might receive an epidural injection of a local anesthetic and/or narcotic (62318) for postoperative pain control in addition to the general anesthetic, which is administered through an endotracheal tube (00540)
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In this case, the epidural is not the surgical anesthetic, and it would be reported separately as an independent procedure
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It should be noted that moderate (conscious) sedation is not an anesthesia service
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To report moderate (conscious) sedation provided by a physician also performing the service for which conscious sedation is being provided, see codes 99143-99145
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Moderate sedation does not include minimal sedation (anxiolysis), deep sedation, or monitored anesthesia care (00100-01999)
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There are certain CPT code descriptors in the CPT codebook that include the phrases "with anesthesia" or "requiring anesthesia
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" These phrases indicate that the work involved in performing the procedure requires anesthesia, whether it is general anesthesia, regional anesthesia, or monitored anesthesia care (MAC), and the appropriate code is separately reported
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To report regional or general anesthesia provided by a physician who also performs the services for which the anesthesia is being provided, use modifier 47, Anesthesia by surgeon, appended to the surgical procedure code, instead of the anesthesia code
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(The use of modifier 47 will be discussed further in Chapter 10
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) Moderate (conscious) sedation: Drug-induced depression of consciousness during which patients respond purposefully to oral commands, either alone or accompanied by light tactile stimulation
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No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate
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Cardiovascular function is usually maintained
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Anesthesia: Induction or administration of a drug to obtain partial or complete loss of sensation
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General anesthesia: A drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation
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Assistance in maintaining a patent airway is usually required
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General anesthesia requires the undivided attention of a separate provider who is well trained and appropriately licensed in the monitoring and rescue functions inherently required for the safe provision of general anesthesia
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Regional anesthesia: The use of local anesthetics to temporarily block large groups of sensory nerves or the spinal cord so that the pain signal cannot reach the brain
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Regional anesthesia also often results in blockage of motor neurons
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This technique is separate and distinct from the use of local anesthesia to numb distal parts of the extremities by numbing nerves that are in proximity to their terminations
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Thus, for the purposes of CPT definitions, regional anesthesia does not include use of local anesthesia below the elbow or ankle
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Local anesthesia: The use of local anesthetics to numb sensory nerves that are in proximity to their terminations
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This will result in only a small area being numbed, such as a circumscribed area of the integumentary or part of a foot or hand
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Motor nerve blockage occurs significantly less frequently with local anesthesia
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Monitored Anesthesia Care (MAC): MAC is a specific anesthesia service for a diagnostic or therapeutic procedure that involves giving sedatives through an intravenous catheter (IV) into the patient's blood stream and is frequently combined with general or regional anesthesia
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Anesthesia modifiers: These are used to indicate the patient's condition at the time anesthesia is administered
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Physical status modifiers: These are used to distinguish among various levels of complexity of the anesthesia service provided, and are represented by the initial letter "P" followed by a single digit from 1 to 6
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1
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List the four different types of anesthesia
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___________, ___________, ___________ and ___________
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If the anesthesiologist performs other additional procedures, each is separately reportable
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Anesthesia Modifiers Anesthesia modifiers are used to indicate the patient's condition at the time anesthesia is administered
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These services are reported with the anesthesia five-digit procedure codes (00100-01999) and two-digit physical status modifiers, as appropriate
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It may also be appropriate to report other CPT modifiers when codes for procedural services are reported in addition to basic anesthesia service
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The physical status modifiers are found in the anesthesia guidelines and identified with the initial letter "P" followed by a single digit from 1 to 6
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The following physicial status modifiers are located in the anesthesia guidelines of the CPT codebook and are defined as follows: P1: A normal healthy patient P2: A patient with mild systemic disease P3: A patient with severe systemic disease P4: A patient with severe systemic disease that is a constant threat to life P5: A moribund patient who is not expected to survive without the operation P6: A declared brain-dead patient whose organs are being removed for donor purposes Qualifying Circumstances Providing anesthesia services, at times, can be complicated depending on the complexity of the medical condition of the patient
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The qualifying circumstances codes (99100-99140) represent important qualifying circumstances that significantly affect the character of the anesthesia service provided
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These types of cases include: Extraordinary condition of the patient Notable operative conditions Unusual risk factors It would not be appropriate to report add-on codes (99100-99140) alone
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They are to be used only with anesthesia codes and not with other procedure codes in the CPT codebook
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Each of these codes are designated as add-on codes and thus must be reported in addition to the procedure number along with the primary anesthesia service provided
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More than one qualifying circumstances code may be selected and reported, as appropriate
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Anesthesia for procedures involving plastic repair of cleft lip 99100 Anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure) However, there is one exception, code 99100, Anesthesia for patient of extreme age, younger than 1 year and other than 70 (List separately in addition to code for primary anesthesia procedure), should not be reported in addition to an anesthesia code that is specific to a very young patient
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Induction of anesthesia for a 75-year-old patient during repair of a cleft lip, the coding would be: 00102
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Note that it is not appropriate to use code 99100 with the anesthesia codes that apply to specific procedures performed on young infants (eg, codes 00834-00836, anesthesia for hernia repairs
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code 00326, anesthesia for procedures on the larynx and trachea
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and code 00561, pump oxygenator cardiac procedures, all on patients younger than 1 year of age)
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Book II Complete Principles of CPT Coding Book III Coding for the administration of anesthesia and any additional procedures or services may seem straightforward
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however, widely varying payer reporting requirements can add complexity to coding for both categories of services
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In particular, claims for separate procedures or services may be denied, be bundled into anesthesia administration, require special payer-specific modifiers, or be misinterpreted by persons not familiar with anesthesia services
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This chapter explores the Anesthesia section of the CPTR code set
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The first step toward understanding how to code for anesthesia services and for any additional procedures or services provided is to develop an understanding of the Anesthesia Guidelines
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This chapter will review the following: Subsections in the Anesthesia section of the CPT code set Services included in basic anesthesia administration services Time reporting for anesthesia services Use of modifiers with anesthesia codes Use of codes for reporting qualifying circumstances for anesthesia services Reporting Basic Anesthesia Administration Services Basic anesthesia administration services are the services provided by or under the responsible supervision of a physician and include the following: Routine preoperative and postoperative visits to evaluate the patient for the planned anesthesia and monitor the patient's postsurgery recovery from anesthesia Administration of fluids and/or blood during the period of anesthesia care Interpretation of noninvasive monitoring such as electrocardiography, body temperature, blood pressure, oximetry (blood oxygen concentration), capnography (blood carbon dioxide concentration), and mass spectrometry Invasive forms of monitoring (such as intraarterial, central venous, and pulmonary artery catheters and transesophageal echocardiography) are not included in basic anesthesia administration services
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When these procedures are performed, they should be reported separately according to standard CPT coding guidelines applicable to the given code and the respective CPT section in which they are listed
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Anesthesia administration services may be reported by using the appropriate code in the Anesthesia section of the CPT code set (00100-01999), the appropriate anesthesia modifier, and qualifying circumstances codes, as appropriate
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Generally, a single code is reported for anesthesia administration, whether one or multiple procedures are performed during a single anesthesia service
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When multiple procedures are performed during a single anesthetic administration, usually only the anesthesia procedure code for the most complex service and the total time for all procedures are reported
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Anesthesia add-on codes are an exception
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Codes 01953, 01968, and 01969 describe anesthesia add-on procedures, which are reported in addition to the primary anesthesia code
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EXAMPLE Neuraxial labor anesthesia services are provided to a 30-year-old patient who had planned a vaginal delivery
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however, circumstances resulted in a cesarean delivery
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In this case, the anesthesia service is reported for the planned vaginal delivery (01967)
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Then, on a separate line, the code for the anesthesia for the cesarean delivery that followed (01968) is reported
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Modifier 51 should not be appended to the add-on code 01968
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(Chapter 8 provides further discussion of modifiers
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) EXAMPLE An anesthesiologist percutaneously inserts an arterial line for monitoring in addition to providing the basic anesthesia administration service for the operation
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In this case, the anesthesia services are reported on one or more lines of the claim form (as appropriate and required by the third-party payer)
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Then, on a separate line, the code for the percutaneous insertion of the arterial line (36620) is reported
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On the basis of CPT coding guidelines, no modifier is appended to code 36620
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There are certain CPT code descriptors in the CPT code set that include the phrases "with anesthesia" or "requiring anesthesia
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" These phrases indicate that the work involved in performing that procedure requires anesthesia, whether it is general anesthesia, regional anesthesia, or monitored anesthesia care (MAC)
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The appropriate anesthesia code is separately reported
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Moderate (conscious) sedation is not an anesthesia service
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Regional or general anesthesia administered by a surgeon who also performs the concomitant procedural services for which the anesthesia is provided is reported using modifier 47, Anesthesia by surgeon, appended to the surgical procedure code, instead of the anesthesia code
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(The use of modifier 47 is discussed further in Chapter 8
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) Types of Anesthesia The American Society of Anesthesiologists (ASA) has defined general, regional, and local anesthesia as follows: General anesthesia is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation
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Assistance in maintaining a patent airway is usually required
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General anesthesia requires the undivided attention of a separate provider who is well trained and appropriately licensed in the monitoring and rescue functions inherently required for the safe provision of general anesthesia
question
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Regional anesthesia is the use of local anesthetic and/or other medication to temporarily block large groups of sensory nerves or the spinal cord so that a pain signal cannot reach the brain
question
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Regional anesthesia also often results in a blockade of motor neurons
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This technique is separate and distinct from the use of local anesthesia to numb immediately adjacent areas, such as fingers or toes, which is local anesthesia
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Local anesthesia refers to the use of local anesthetics to numb sensory nerves that are in immediate proximity to their terminations
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This will result in only a small adjacent area being numbed, such as a circumscribed area of the skin or mucous membrane, finger, or toe
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Motor nerve blockage occurs significantly less frequently with local anesthesia
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Monitored Anesthesia Care (MAC) The ASA has defined monitored anesthesia care as follows: MAC is a specific anesthesia service for a diagnostic or therapeutic procedure
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Indications for MAC include the nature of the procedure, the patient's clinical condition, and/or the potential need to convert to a general or regional anesthetic
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MAC includes all aspects of anesthesia care: a preprocedure visit, intraprocedure care, and postprocedure anesthesia management
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During MAC, the anesthesiologist provides or medically directs a number of specific services including, but not limited to, the following: Diagnosis and treatment of clinical problems that occur during the procedure Support of vital functions Administration of sedatives, analgesics, hypnotics, anesthetic agents, or other medications as necessary for patient safety Psychological support and physical comfort Provision of other medical services as needed to complete the procedure safely When MAC is chosen as the anesthetic, it differs from moderate (conscious) sedation in that the potential for progression from MAC to general anesthesia is always present
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Time Reporting Time spent providing the anesthesia service is reported separately when anesthesia services are coded
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Anesthesia time begins when the anesthesia provider starts preparing the patient for anesthesia in the operating room or a similar location
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Time ends when the patient is safely placed under postoperative supervision
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CODING TIP Time spent providing the anesthesia service is reported separately when anesthesia services are reported
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The guidelines for time-based codes in the Introduction of the CPT code set do not apply to the anesthesia service codes (00100-01999) because of the unique aspects of anesthesia service coding and billing
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Anesthesia Modifiers All anesthesia services are reported with the 5-digit anesthesia procedure code (00100-01999) and 2-digit physical status modifier, as appropriate
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The use of other CPT modifiers may also be appropriate
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The physical status modifiers are found in the Anesthesia Guidelines
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They are identified with the initial letter P followed by a single digit from 1 to 6 and defined as follows: P1 A normal, healthy patient P2 A patient with mild systemic disease P3 A patient with severe systemic disease P4 A patient with severe systemic disease that is a constant threat to life P5 A moribund patient who is not expected to survive without the operation P6 A declared brain-dead patient whose organs are being removed for donor purposes The 6 levels of physical status modifiers indicated are consistent with the ASA ranking of patient physical status
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Physical status is included in the CPT code set to distinguish the various levels of complexity of the anesthesia service provided
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Reporting Multiple Surgical Procedures When multiple surgical procedures are performed during a single anesthetic administration, the anesthesia code representing the most complex procedure is reported
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The time reported is the combined total for all procedures
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Add-on anesthesia codes are an exception
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They are reported in addition to the code for the primary anesthesia service
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Anesthesia for second- and third-degree burn excision or debridement with or without skin grafting, any site, for total body surface area (TBSA) treated during anesthesia and surgery
answer
There are 3 add-on anesthesia codes: 01953
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Anesthesia for cesarean delivery following neuraxial labor analgesia/anesthesia (List separately in addition to code for primary procedure performed) 01969 Anesthesia for cesarean hysterectomy following neuraxial labor analgesia/anesthesia (List separately in addition to code for primary procedure performed) When the secondary anesthesia service is designated as an add-on procedure in the CPT code set, it should be reported in conjunction with the primary procedure
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each additional 9% total body surface area or part thereof (List separately in addition to code for primary procedure) 01968
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Separately Reportable Services Placement of invasive monitoring devices and the use of transesophageal echocardiography may be reported separately in addition to the basic anesthesia service or procedure
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Procedures performed to provide for postoperative pain management are also separately reportable
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EXAMPLE An anesthesiologist inserts a centrally-inserted, non-tunneled central venous catheter in addition to providing the anesthesia service for a diagnostic or therapeutic surgical procedure
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The anesthesiologist also inserts an epidural catheter into the lumbar spinal region to induce continuous postoperative analgesia for therapeutic pain management
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The anesthesiologist reports the appropriate anesthesia code for the surgical procedure (00100-01999) as well as the codes for the central venous line (36556) and the epidural that was placed for postoperative pain management (62319)
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Some payers may require that modifier 59, Distinct procedural service, be appended to the code for the epidural
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CODING TIP When adjunctive procedures (eg, atrial line placement, epidural catheter insertion) are performed by the same individual prior to anesthesia administration, or after anesthesia is concluded, the time taken to place the line or insert the catheter into the lumbar region, is deducted from the reported anesthesia time
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This deduction prevents double billing for services rendered during a single span of time
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Codes 36556, 36620, and 93503 are other examples of adjunctive invasive monitoring procedures that may be performed at the same time as anesthesia services
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While the interpretation of the data obtained from these devices is included in the base unit value assigned to an anesthesia code, the placement of these devices is not
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Therefore, the placement should be reported separately
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Reporting Other CPT Modifiers In addition to the physical status modifiers, it may also be appropriate to report other CPT modifiers when codes for procedural services are reported in addition to the basic anesthesia service
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If an anesthesiologist performs other additional procedures, each is separately reportable
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EXAMPLE An anesthesiologist places a centrally-inserted, non-tunneled central venous catheter in addition to providing the anesthesia administration service for the operation
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answer
The anesthesiologist also inserts an epidural catheter into the lumbar spinal region to induce continuous postoperative analgesia for therapeutic pain management
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answer
In this case, the anesthesia service is reported on one or more lines of the claim form (as appropriate and required by the third-party payer)
question
Insertion of non-tunneled, centrally-inserted central venous catheter
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The following codes are the additional procedures performed: 36556
question
Injection(s), including indwelling-catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, includes contrast for localization when performed, epidural or subarachnoid, lumbar or sacral (caudal)
answer
age 5 years or older (report code 36555 for patients under age 5) 62319
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Code 36556 should be reported for patients 5 years of age or older
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Code 36555 should be reported for patients younger than 5 years of age
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Modifier 51 is appended to code 36556 as this procedure that is not designated as modifier 51 exempt
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Modifier 59 is appended to the epidural catheter pain procedure to indicate that it is distinct or independent of the anesthesia service
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Codes 36620 and 93503 are other examples of adjunctive invasive monitoring procedures that might be performed at the same time as anesthesia services
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As these codes are designated as modifier 51 exempt, modifier 51 would not be appended to these procedure codes when reported in addition to the anesthesia service codes
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answer
(Chapter 8 provides further discussion regarding codes exempt from the use of modifier 51
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answer
) EXAMPLE A patient undergoing a thoracotomy receives an epidural injection of a local anesthetic for postoperative pain control in addition to the general anesthetic administered through an endotracheal tube
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answer
In this case, the epidural (62318) is not the surgical anesthetic (00540), and it would be reported separately as an independent procedure
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answer
When general anesthesia is administered and epidural or nerve block injections are performed to provide postoperative analgesia, they are separate and distinct services and are reported in addition to the anesthesia code, irrespective of the timing (preoperatively, intraoperatively, or postoperatively) of the placement of the block (insertion of catheter, injection of narcotic or local anesthetic agent)
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EXAMPLE A patient undergoes total knee replacement surgery, receiving a regional anesthetic and a postoperative pain management agent through the same epidural catheter
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When the block procedure is used primarily for the anesthesia itself, the service should be reported using the anesthesia code alone (01402)
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In a combined epidural and general anesthetic, the block cannot be reported separately
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Qualifying Circumstances Many anesthesia services are provided under particularly difficult circumstances, depending on factors such as the following: Extraordinary condition of the patient Notable operative conditions Unusual risk factors Four codes (see the following list) are available for reporting qualifying circumstances that have a significant impact on the anesthesia service provided
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These codes can be found at the end of the Anesthesia Guidelines and in their appropriate numeric sequence in the Medicine section of the CPT code set
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These codes are designated as add-on procedures and may be reported in addition to the primary anesthesia procedure or service, with the exception of code 99100, which should not be reported in addition to an anesthesia code that is specific to very young patients (ie, 00326, 00561, 00834, 00836)
question
Anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure) 99116 Anesthesia complicated by utilization of total body hypothermia (List separately in addition to code for primary anesthesia procedure) 99135 Anesthesia complicated by utilization of controlled hypotension (List separately in addition to code for primary anesthesia procedure) 99140 Anesthesia complicated by emergency conditions (specify) (List separately in addition to code for primary anesthesia procedure) Note that it is not appropriate to use code 99100 with the anesthesia codes that apply to specific procedures performed on young infants (codes 00834-00836, which are for reporting anesthesia for hernia repairs
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99100
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code 00326, used to report anesthesia for procedures on the larynx and trachea
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answer
and code 00561, which describes pump oxygenator cardiac procedures on patients younger than 1 year)
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For the purposes of reporting code 99140, an emergency is defined as existing when delay in treatment of the patient would lead to a significant increase in threat to life or body part
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This definition does not refer to a procedure merely because it is done outside of the normal, weekday schedule
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If an elective procedure is delayed into evening hours, it is not considered an emergency
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Each of the preceding codes is considered an add-on code and is reported as an additional procedure code along with the code for the anesthesia service provided
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It is not appropriate to report these codes alone
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They are to be used only with anesthesia codes and not with other procedure codes in the CPT code set
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As with all add-on codes, these codes are exempt from the use of modifier 51
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More than one qualifying circumstances code may be selected and reported, as appropriate
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Book III Complete
