Chapter 16 Anesthesia – Flashcards

Grouped anatomically, beginning with the head. To find, either use Index / Anesthesia to locate the anatomic area or turn to blue edged Anesthesia 000100 pages. Guidelines are at front of blue chapter.

Books available to coders to assist by "crosswalking" the known surgical code to an appropriate anesthesia code.

Base unit value.

General, Regional, and Monitored Anesthesia Care (MAC)

A drug-induced loss of consciousness. Where the patient is unconscious and has no control of their airway.

Includes blocks, spinals, and epidurals. A loss of sensation in a region of the body such as: Spinal Anesthesia: An anesthetic agent is injected in the subarachnoid space into the cerebral spinal fluid (CFS) in the patient's spinal canal for surgeries performed below the upper abdomen. Epidural Anesthesia: An anesthetic agent is injected in the epidural space. A small catheter may be placed for a continuous epidural. An epidural can also remain in place after surgery to assist with postoperative pain. Nerve Block: An anesthetic agent is injected directly into the area around a nerve to block sensation for the region the surgery is being performed. Commonly used for procedures on the arms or legs.

MAC. Anesthesia service where the patient is under light sedation or no sedation while undergoing surgery with local anesthesia provided by the surgeon. The patient can respond to purposeful stimulation and can maintain his airway. The service is monitored by an anesthesia provider who is prepared at all times to convert MAC to general anesthesia if necessary. For MAC, the patient has a decreasedawareness and he or she cannot easily be aroused, but will respond to painful or repeated stimuli. They are not totally unconscious and they are able to control their airway.

is used for minor surgeries. For local anesthesia, the services are included in the CPT® code for the surgical encounter. There would not be a separate code for anesthesia services.

A physician licensed to practice medicine and has completed an accredited anesthesiology program. These physicians may personally perform, medically direct, or medically supervise members of an anesthesia care team.

Certified Registered Nurse Anesthetist. A registered nurse who has completed an accredited nurse anesthesia-training program. The CRNA may be either medically directed by an anesthesiologist or non-medically directed.

Anesthesiologist Assistant. A health professional who has completed an accredited Anesthesia Assistant training program. The AA may only be medically directed by an anesthesiologist

A physician who is completed his medical degree and is a residency program specifically for anesthesiology training.

Student Registered Nurse Anesthetist. A registered nurse who is training in an accredited nurse anesthesia program.

OVL. A term used in anesthesia related to thoracic surgery. is when the two lungs are not working together because either they are trying to protect one lung from either infection or blood. This would a be reported in the anesthesia records so it would be clear when the service is being provided. OLV occurs when one lung is ventilated and the other lung is collapsed temporarily to improve surgical access to the lung. Several anesthesia codes separately identify utilization of one-lung ventilation.

Is the bypass machine (cardiopulmonary bypass machine, CPB) they put patients on during cardiac procedures when they are working on the heart. When a procedure code description states, "with pump oxygenator," this is when they put the patient on that heart and lung machine which is also known as the bypass machine. Describes when a cardiopulmonary bypass (CPB) machine is used to function as the heart and lungs during heart or great vessel surgery. Cpb maintains the circulation of blood and the oxygen content of the body. When a CPB machine is used, the anesthesia record should describe when the patient went on and off pump. When a pump oxygenator is not used, the surgeon is operating on a "beating" heart.

describes organs within the peritoneum. These procedures may be performed in both the upper and lower abdomen. Intraperitoneal organs in the upper abdomen include the stomach, liver, gallbladder, spleen, jejunum, and ascending and transverse colon. Intraperitoneal organs in the lower abdomen include the appendix, cecum, ileum, and sigmoid colon. Because the cecum and ileum are part of the small intestines and originate in the upper abdomen, these may be coded as upper abdomen.

describes the anatomic space in the abdominal cavity behind the peritoneum. The kidneys, adrenal glands, and lower esophagus are extraperitoneal organs of the upper abdomen. Extraperitoneal organs in the lower abdomen include the ureter and urinary tract. Also located in the retroperitoneum are the aorta and inferior vena cava.

It doesn't matter where the trocars are placed for laparoscopic procedures, code assignment is dependent on actual procedure being done.

Is usually extensive, complex, and intendedto correct a severe health threat, such as a rapidly growing cancer.

May be performed on the temporomadibular joint, shoulder, elbow, wrist, hip, knee, and ankle. Coders should assign only a diagnostic code when no surgical procedure is performed. EX: Knee arthroscopy is listed as "diagnostic" and a meniscectomy is performed, surgical arthroscopic meniscectomy code is assigned.

Usually the responsibility of the surgeon, and payment is bundled into the surgeon's global fee. However, it may be requested by the surgeon and billed separately by anesthesia as long as the anesthesia for the surgical procedure is not dependent on the efficacy of the regional anesthetic technique. EX: if epidural is mode of anesthesia for procedure, it cannot be reported for post operative pain management.

Depends on what is injected, the site of injection and placement of either a single injection block or continuous block by catheter. Pay close attention to whether it is single injection or continuous infusion. CPT code reported is appended with modifier 59 to signify the service is separate and distinct from anesthesia care provided for the surgery.

When utilized and appropriately documented, codes are reported with modifier 26 (professional component) unless code selected includes imaging guidance (fluoroscopy or CT).

EX: 64415 Brachial plexus block. May be used as an adjunct to general anesthesia if placement is for postoperative pain management. Nerve block codes should not be reported separately if the block is the mode of anesthesia for a procedure being performed. EX: Carpal tunnel procedure performed with axillary block, code from anesthesia section ( 01810+related anesthesia time) is reported. No separate code is reported for axillary block.

The preoperative and postoperative visits performed by the anesthesia provider, the anesthesia during the procedure, administration of fluids and/or blood and any usual monitoring services. Examples of usual monitoring are EKGs, blood pressures, and monitoring the patient's temperature. The unusual forms of monitoring include the intraarterial lines, also known as A lines; central venous lines, which are also known as CVPs; and Swan-Ganz catheters. These three items or these three services would also be coded in addition to the anesthesia code when they are provided.

The first manual is the Anesthesia Crosswalk. It is organized differently than CPT®. The Crosswalk is organized by surgical CPT® code. The anesthesia coder would look up the CPT® code for the surgery provided and that would give them what the anesthesia code is, that gives you a crosswalk. There are also some other products available by other vendors that do the same thing, but the ASA is the organization that publishes the Anesthesia Crosswalk. Anesthesia Relative Value Guide®, which gives the relative value for each one of the anesthesia codes. The relative value is a numeric ranking assigned to a procedure in relation to other procedures in terms of work and cost. The relative values are also referred to as base units. These values are important because they help us determine what the anesthesia units are for a case. This is also utilized in determining how to calculate our fees for anesthesia services. It is important for us to understand these values and how they are used. The values are assigned to the actual anesthesia code.

is a numeric ranking assigned to a procedure in relation to other procedures in terms of work and cost. The relative values are also referred to as base units. These values are important because they help us determine what the anesthesia units are for a case. This is also utilized in determining how to calculate our fees for anesthesia services. It is important for us to understand these values and how they are used. The values are assigned to the actual anesthesia code.

Reported for continuous administration of anesthesia for postoperative pain management. If the infusion catheter is placed for operative anesthesia, the appropriate anesthesia code plus time is reported. If the continuous infusion catheter is placed for postoperative pain management, the daily postoperative management of the catheter is included.

Assigned for daily hospital management of epidural or subarachnoid continuous drug administration. Continuous infusion by catheter such as femoral (64448) or sciatic (64446) is not an epidural catheter; 01996 is never reported with these codes. Anesthesiologists may report an appropriate E/M service to re-evaluate postoperative pain if documentation supports the level of service reported and billed.

Reported when anesthesia is injected into the epidural space of the spine, including the cervical, thoracic, or lumbar area. May be either single injection or continuous catheter.

Reported when anesthesia, opioids, or steroids are injected into the subarachnoid or cerebrospinal fluid (CSF) space. May be either single injection or continuous catheter.

-Identify reason for anesthesia service -Review for other pertinent information and supporting diagnosis codes -Check Alphabetic Index and then check the code in the Tabular List -Locate main entry term -Pay attention to notes listed in main terms -Understanding coding conventions (See ICD-9-CM Official and Additional Conventions) -Look for additional instructions in the tabular (numeric) section -Make sure code is to highest level of specificity -Assign pertinent related ICD-9 code

Identified in 338 section. when provider is treating post-operative pain, a code from cat 338 is selected based on whether pain is acute or chronic. When the underlying condition causing the pain is treated, do no treport a code from cat 338. Instead, report code for condition causing the pain. Guidelines I.C.6

Procedures common carried out in addition to the primary procedure performed. Add-on codes may NOT be reported alone, and are identified with a + sign

A health professional who has completed an accreditied Anesthesia Assistant training program.

A physician who is licensed to practice medicineand has completed an accredited anesthesiology program.

Begins when the anesthesiologist ( or anesthesia provider) begins to prepare the patient for the induction of anesthesia and ends when the anesthesiologist (or anesthesia provider) is no longer in personal attendance.

A catheter inserted into an artery. It is used most commonly to measure real-time blood pressure and to obtain samples for arterial blood gas.

Value assigned to anesthesia codes for anesthetic management of surgery and diagnostic tests. Base unit values will vary depending on the difficulty of the surgery or diagnostic tests, and the management of anesthesia.

A technique used during heart surgery to take over temporarily the function of the heart and lungs.

A catheter placed in a large vein such as the internal jugular, subclavian, or femoral vein with the tip of the catheter close to the atrium, or in the right atrium fof the heart.

EX; arterial lines, central venous (CV) catheters and pulmonary artery catheter (eg, Swan-Ganz). These are not included in the base code but need to be coded as well and billed separately.

These are determined by the difficulty of the procedure. Specialty books specific to anesthesia coding contain base values for each anesthesia code. Medicare also publishes a list of base values, available on its website under Anesthesiologists Center.

Determining base value is first. Time reporting is second.

Time begins when anesthesiologist begins to prepare patient for surgery in either the the operating room or an equivalent area. Pre-anesthesia assessment time is NOT part of the reportable time. It is considered part of the base value assigned. Ending time is reported when anesthesiologist is no longer in personal attendance, usually when patient given over to post-operative care. Accrued time time reporting does not need to be continuous. EX; An axillary block may be performed in holding room ( if block is mode of anesthesia). Block took 15 mins to perform. When patient in operating room and anesthesiologist needed, time starts again for duration of surgery. Block- 15 mins +Surgery- 60 mins= 75 mins of time. Time reporting on claims may vary according to company. Some companies round to the nearest 5 min increment. Medicare does not round. They require exact time reporting.

They utilize exact time reporting and use a formula. EX: Time starts at 11:02 and ends at 11:59, the time is reported as 57 mins. Medicare divides that 57 mins by 15min increments, 57 divided by 15=3.8 units. If the procedure has a base value of 6 units, the time units are added for a total of 9.8 units, which is then multiplied by the Anesthesia Conversion Factor for geographic location. (Using 2012 Anesthesia Conversion Factor assigned to Salt Lake City, Utah of 21.44, the total Medicare payment is 210.11 [9.8 x 21.44=210.11]

The process depends on their increment reporting. It can be exact or could vary to 10, 12, 15 mins or some other time increment but the math still stays the same. EX: Time start 11:02, time end 11:59. 57 mins duration. If the procedure has a base value of 4 units, and the 57 min duration is divided by 10 min increment, the time value is 5.7, which may be rounded up to 6 depending of=n the insurance. By adding 6 time units to the base value of 4 units there is a total of 10 units, which is then multiplied by the applicable Anesthesia Conversion Factor.

The surgery that is most complex is reported because it has the highest base unit value. Because only one "procedure" is reported, regardless of how many are performed, a Mod 51 is not added to anesthesia code. Total time of all procedures are reported as anesthesia time. Exception to this is when there is an anesthesia add-on code.

When the patient has additional add-on code procedure s applicable to the anesthesia service. These add-on codes are under Burn Excision or Debridement and Obstetric codes. These may not be reported alone and must be reported with the applicable primary anesthesia code in parenthesis. EX: A TBSA of 40 percent is repoprted as follows: 01952 + TM First 4 to 9 percent of TBSA +01953 x 4 Represents the remaining 31 percent of TBSA in increments of 9 percent (the remaining 4 percent is considered a "part thereof") NOTE: The first anesthesia code, 01952 is reported with time units. The add-on code 01953 is reported in units only.

They describe the physical status of the patient. Consider these "Risk Points". These are not recognized by Medicare and no base values are assigned in CPT. However, most non-Medicare payers typically pay additional base units. P1- A normal healthy patient (knee replacement)- No extra value added P2- A patient with mild systemic disease- No extra value added P3- Patient with severe systemic disease - 1 extra unit P4- Patient with severe systemic disease that is a constant threat to life- 2 extra units P5- Moribund patient who is not expected to survive without the operation - 3 extra units P6- Declared brain-dead patient whose organs are being removed for donor purposes - No extra value added

The anesthesia code selected is appended with the appropriate P modifier. EX: Patient with severe systemic disease that is a constant treat to life is undergoing a direct coronary artery bypass graft (CABG) with a pump oxygenator is reported as 00567-P4

CABG - 18 units. (per Medicare based unit value for anesthesia), Anesthesia time unit - 20, 2012 Anesthesia Conversion Factor ( Salt Lake City) - $21.44 Medicare ( no physical status recognized) payment: 18 + 20 x 21.44=814.72 Non- Medicare: 18 + 20 + 2 x 21.44 = 857.60

Anesthesia add-on codes assigned to report anesthesia services performed under difficult circumstances affecting significantly the character of anesthesia services. Each code identifies a different circumstance and more than one may be used unless the reported code already contains the risk factor. Codes have parenthetical reference underneath specifying the qualifying circumstance when the code is not reported with referenced code. These are not recognized by Medicare for additional payment and no base values are listed in CPT. ASA assigned base unit values for QC: +99100 - Anesthesia for patient of extreme age, younger than 1 yr and older than 70 yrs - 1 unit +99116 - Anesthesia complicated by utilization of total body hypothermia - 5 units +99135 - Anesthesia complicated by utilization of controlled hypotension - 5 units +99140 - Anesthesia complicated by emergency conditions (specify) - 2 units Documentation must support QC code reported. Emergency conditions do NOT apply to after normal-hour care or routine obstetric labor.

Defined as existing when a delay in treatment of the patient would lead to a significant increase in the threat to the patient's life or body parts.

Time is not reported separately for payment. Flat fee services are not included in the anesthesia time. EX: An epidural is placed for pain management prior to the induction of anesthesia, and an arterial line is also placed, the time for these services are not counted in total anesthesia time. EX: A CV catheter is inserted and used to thread a pulmonary artery catheter (PAC), only the PAC code 93503 [Insertion and placement of flow directed catheter (eg Swan-Ganz) for monitoring purposes] is reported. If a central venous cath and Swan-Ganz are separately placed, each procedure is reported. The central venous line will require Mod 59 to show it was completely separate and necessary. Payments for these services are based on the physician fee schedule , as are other surgical services. Monitoring is NOT reported separately.

31500 - Intubation, endotracheal, emergency procedure: Emergency intubation may be reported separately when an anesthesia provider is requesting to intubate a patient who is NOT undergoing anesthesia. Normal intubation is included in base value of anesthesia code. 36620 - Arterial Catheterization or cannulation for sampling monitoring or transfusions; percutaneous (placed in a radial artery through needle puncture of the skin) 36555 or 36556 - Insertion of non-tunneled centrally inserted central venous catheter: Because these codes are age-related, the appropriate code assignment is based on whether the patient is under 5yrs or older. 93503 - Insertion and placement of flow directed catheter for monitoring purposes (eg. Swan-Ganz)

Conscious sedation. 99143-99150 Provided without anesthesia equipment and back up for general anesthesia. A physician who is also performing the service for which conscious sedation is being provided may report moderate sedation codes. Moderate sedation can also be provided by a physician other than the surgeon; and an anesthesiologist may provide moderate sedation in these circumstances. Moderate sedation codes do not include minimal sedation ( anxiolysis), deep sedation or monitored anesthesia care. These are located in ANES section and only anesthesia providers report these codes.

minimal sedation

Distinctly different from moderate sedation. May involve administration of sedatives, analgesics, hypnotics, anesthetic agents, or other medications necessary patient safety based on each patient's health status. Patient does not lose consciousness, is arousable, and is able to maintain an open airway. When using MAC, provider must be qualified and prepared at all times to convert to general anesthesia, if necessary. If the patient loses consciousness and the ability to respond purposefully, the anesthesia care is a general anesthetic. MAC services are paid in the same way as general or regional anesthesia services are paid.

This modifier may be reported to describe a procedure usually not requiring anesthesia ( either none or local) but, due to unusual circumstances, is performed under general anesthesia.

This modifier is reported by the surgeon when he also provides a regional or general anesthesia for the surgical service, and does not apply to local anesthesia. This is not to be reported with anesthesia procedure codes. Anesthesia providers do not report this modifier.

This modifier may be reported to describe a procedure started and, due to extenuating circumstances, was discontinued. Although this modifier is not strictly anesthesia related, carrier policy often identifies this as the modifier to report when anesthesia services are discontinued.

This modifier is used to indicate a procedure or service is distinct or independent from other Non-Evaluation and Management procedures. Documentation must support a different session, procedure, surgery, site, organ system, incision/excision, or injury. This modifier is often appended to post-operative pain management services to indicate it is separate from the anesthesia administered during the surgery.

This modifier is listed as approved for ASC and hospital outpatient use. Although this modifier is not strictly anesthesia related, carrier policy often identifies this as the modifier to report when anesthesia services are discontinued after administration of anesthesia. NOTE: Physician reporting of discontinued procedures is referred to Mod 53.

This modifier is listed as approved for ASC and hospital outpatient use. Although this modifier is not strictly anesthesia related, carrier policy often identifies this as the modifier to report when anesthesia services are discontinued after administration of anesthesia. Note: Physician reporting of discontinued procedures is referred to Mod 53.

Occurs when an anesthesiologist is involved in 2-4 anesthesia procedures at the same time; or a single anesthesia procedure with a qualified anesthesia resident, CRNA, or anesthesiologist assistant.

1. Perform a pre-anesthetic examination and evaluation. 2. Prescribe the anesthesia plan. 3. Personally participate in the most demanding procedures of the anesthesia plan including, if applicable, induction and emergence. 4. Ensure that any procedures in the anesthsia plan that he or she does not perform are performed by a qualified anesthetist. 5. Monitor the course of anesthesia administration at frequent intervals. 6. Remain physically present and available for immediate diagnosis and treatment of emergencies. 7. Provide the indicated post anesthesia care. IF one or more of the above services are NOT performed by the anesthesiologist, then service is not considered medial direction.

-Addressing an emergency of short duration in the immediate area. -Administering an epidural or caudal anesthetic to ease labor pain. - Monitoring an obstetrical patient periodically rather than continuously. - Receiving patients entering the operating suite for the next surgery. - Checking on or discharging patients from the post anesthesia care unit. - Coordinating scheduling matters.

Occurs when an anesthesiologist is involved in 5 or more anesthesia procedures during the same time (concurrent); or when the anesthesiologist does not perform the required services listed under medical direction. Non-medically directed CRNAs are working without medical direction.

-Pre-anesthetic examination and evaluation -Prescription of the anesthesia care required -Completion of an anesthesia record -Administration of any necessary oral or parenteral medication -Provision of indicated postoperative anesthesia care The anesthesiologist, CRNA, or qualified individual under medical direction of an anesthesiologist, must be continuously present to monitor the patient and provide anesthesia care. They must be in anticipation of : -The need for administration of general anesthesia -The development of an adverse physiological patient reaction to the surgical procedure

These report if the anesthesiologist personally performed the anesthesia, provided medical Medical supervision of the anesthesia, or provided medical direction of the anesthesia. AA- Anesthesia services performed personally by anesthesiologist AD- Medical supervision by a physician: more than 4 concurrent anesthesia procedures QK- Medical direction of 2,3, or 4 concurrent anesthesia procedures involving qualified individuals QY- Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist GC- This service has been performed in part by a resident under the direction of a teaching physician *Concurrency- refers to all current ongoing anesthesia cases during the same time under the direction or supervision of an anesthesiologist.*

QX-CNRA service: with medical direction by a physician QZ-CNRA service: without medical direction by a physician *Note- State scope of practice may prohibit an anesthesiologist assistant from reporting claims with a non-medical direction modifier. *Note- If the provider (anesthesiologist) moves from QK to AD, the CRNA still reports QXas the CRNA would not necessarily know the number of cases the anesthesiologist is overseeing.

Medical direction modifiers are associated with specific providers and are reported in the first position after the anesthesia code because payment often is related to the modifier reported. ( First rule of coding modifiers- modifiers affecting payment are always reported first) Additional anesthesia-related modifiers usually are reported in the second position after any related medical direction modifiers, as they are considered informational or statistical. Physical status modifiers should be listed in 2nd or 3rd position, as applicable. EX; To report a personally performing physician service with a physical staus 3 patient, 00910-AA-P3. To report the medically directing physician and CRNA service with a physical status 3 patient under monitored anesthesia care (MAC), QK-QS-P3 and 00142 QX-QS-P3

QS- Monitored anesthesia care service G8- Monitored anesthesia care service for deep complex, complicated, or markedly invasive surgical procedure G9- Monitored anesthesia care for patient who has a history of severe cardiopulmonary disease *Note: When reporting G8 or G9 modifier, it is not necessary to report a QS seperately because the description is included already. Only report anesthesia modifiers with anesthesia codes.

www.cms.gov/manuals/downloads/clm104c12.pdf Full chapter to be reviewed prior to billing Medicare *Payment at Personally Performed Rate The Part B Contractor must determine the fee schedule payment, recognizing the base unit for the anesthesia code and one time unit per 15 minutes of anesthesia time if: -The physician personally performed the entire anesthesia service alone -The physician is involved with one anesthesia case with a resident, the physician is a teaching physician as defined in &100, and the service is furninshed on or after January 1 1996; -The physician is involved in the training of physician residents in a single anesthesia case, two concurrent anesthesia cases involving residents or a single anesthesia case involving a resident that is concurrent to another case that is concurrent to another case paid under the medical direction rules. The physician meets the teaching physican criteria in &100.1.4 and the service is furnished on or after January, 1, 2010; _The physician is continuously involved in a single case involving a student nurse anesthetist; -The physician is continuously involved in one anesthesia case involving a CRNA (or AnesAss) and the service was furnished on or after January 1, 1998. If the physician is involved with a single case with a CRNA (or AA) service in accordance with the medical direction payment policy;or -The physician and the CRNA (or AA) are involved in one anesthesia case and the service of each are found to be medically necessary. Documentation must be submitted by both the CRNA and the physican to support payment of the full fee for each of the two providers. The physician reports the "AA" modifier and the CRNA repots the "QZ" modifer for a non-medically directed case. *Payment at the Medically Directed Rate For services furnished on or before January 1, 1994, the physician can medically direct 2,3,or 4 concurrent procedures involving qualified individuals, all of whom could be CRNAs, AAs, interns,residents, or combinations of these individuals. The medical direction rules apply to cases involving student nurse anesthetists if the physician two concurrent cases, each of which involves a student nurse anesthetist, or the physician directs one case involving a student nurse anesthetist and another involving a CRNA, AA, intern, or resident. For services furnished on or after January 1, 2010, the medical direction rules do not apply to a single resident case that is concurrent to another anesthesia case paid under the medical direction rules or to two concurrent anesthesia cases involving residents. The GC modifier is reeported by the teaching physician to indicate he rendered the service in compliance with the teaching physician requirements in &100.1.2. One of the payment modifers must be used in conjunction with the GC modifier.