Basics of Anesthesia Coding in CPT

1.01 Anesthesia Anesthesia located before the surgery section is a section of its own. These services include general and regional anesthesia. When coding anesthesia services, be careful to look for the service for which general anesthesia was performed under the Anesthesia in the CPT index, followed by the body site. Terms to be familiar with in this CPT section include: ➢ Physical status Modifiers: These modifiers are used only in the Anesthesia section with procedure codes to indicate the patients' health status before Anesthesia is provided. ➢ Qualifying Circumstances: These modifiers are used only in the Anesthesia section with the procedure code in the case of difficult or extraordinary circumstances as extreme age (under 1 and over 70). ➢ Basic Value: Each Anesthesia code, published by the American Society of Anesthesiologists, has a basic value also referred to as the relative value, which include services bundled into the anesthesia procedure code in addition to the value of work associated with the anesthesia service. ➢ Preoperative Visit- History and exam performed by the Anesthesiology staff. ➢ Intraoperative Care- including the administration of fluids, monitoring vitals, body temperature, blood pressure and pulse, in addition to the administration of anesthesia ➢ Postoperative Visit- also known as the post anesthesia recovery period. Time Units: Time is used to help determine reimbursement for Anesthesia services. It defines the actual time spent providing the service. Typically, time is documented in minutes converted to units. 15 mins = 1 Unit The time starts when the provider prepared the patient or the induction of anesthesia to the time ending in which the provider is no longer in attendance ant patient is sent to the surgery recovery area. Modifying Unit: Modifying units are determined by the Physical status and any qualifying circumstances. These both can be found in the Anesthesia Guidelines and have an impact on Anesthesia reimbursement. Qualifying Circumstances 99100 – Anesthesia for Patient of Extreme Age, Under 1 Year and Over 70 – 99116 – Anesthesia Complicated By Utilization of Total Body Hypothermia – 99135 – Anesthesia Complicated By Utilization of Controlled Hypotension – 99140 – Anesthesia Complicated – 1 unit 5 units 5 units 1 unit Physical Status Modifiers P1 - A normal healthy patient 0 units P2 - A patient with mild systemic disease 0 units P3 - A patient with severe systemic disease 1 units P4 - A patient with severe systemic disease that is a constant threat to life 2 units P5 - A moribund patient who is not expected to survive without the operation 3 units P6 - A declared brain-dead patient whose organs are being removed for donor purposes 0 units 1.02 Surgery The Surgery section is the largest in the CPT coding manual and arranged by body system. It is important for coders to become familiar with the guidelines related to the surgery section. Becoming familiar with the arrangement of subsections within the CPT allows for easier code selection. Surgical Guidelines Include: • Physician Services- Alerts coders that Physician Services are found in the E/M section • CPT surgical package definitiono Evaluation and Management (E/M) service(s) subsequent to the decision o for surgery on the day before and/or day of surgery (including history and physical) o Local infiltration, metacarpal/metatarsal/digital block, or topical anesthesia o Immediate postoperative care, including dictating operative notes, talking with the family and other physicians or other qualified health care professionals o Writing orders o Evaluating the patient in the post anesthesia recovery area o Typical postoperative follow-up care • Follow-up care for diagnostic and therapist procedures- This care includes only the care related to the recovery from the procedure. • Materials supplied by the physician- If the provider supplied additional materials over what is typically used for the procedure, the provider can bill drugs, trays, supplies and the other materials. • Reporting more than one procedure/service- More than one procedure/service is completed on the same date, session, or during the postoperative period, codes should be appended with CPT modifiers. • Separate procedure- Following some code descriptions are the words ’separate procedure’. These codes report procedures that are typically part of a larger service or procedure and therefore are not reported if the larger procedure is performed. However, if the code description designed as a ‘separate procedure’ is completed alone, then the • • • code is reported. Unlisted service or procedure- These codes should be used only when a more specific code is not available for use. When these codes are used, it is common for payers to request a special report that outlines the description of the following Special report- A service that is rarely provided, unusual, variable, or new may require a special report. Pertinent information should include an adequate definition or description of the nature, extent, and need for the procedure, and the time, effort, and equipment necessary to provide the service. Surgical destruction - Surgical destruction is a part of a surgical procedure and different methods of destruction are not ordinarily listed separately unless the technique substantially alters the standard management of a problem or condition. Exceptions under special circumstances are provided for by separate code numbers. 1.03 Radiology Radiology is a branch of medicine which uses x-rays, magnetic resonance imaging (MRI), computerized axial tomography (CAT), and ultrasounds to diagnose and treat disease. Being familiar with the terminology used in the positioning of a patient as the radiological procedure is performed, helps the coder in code assignment. Anterior Posterior Midline Lateral Medial Superior Inferior Superficial Deep Proximal Distal At or near the front of the body (front view) At or near the back of the body (back view) An imaginary vertical line that divides the body equally (right down the middle) Farther from midline (side view) Nearer to midline (side view) Toward the head/upper part of a structure (bird’seye view, looking down) Away from the head/lower part of a structure (bottom view, looking up) Close to the surface of the body Away from the surface of the body Nearer to the origination of a structure Farther from the origination of a structure Other Anatomical Directional Terms • • • • • • • • • • • • • • Dorsal: Ventral: Lateral: Medial: Rostral: Caudal: Bilateral: Unilateral: Ipsilateral: Contralateral: Parietal: Visceral: Axial: Intermediate: Near the upper surface, toward the back Toward the bottom, toward the belly Toward the side, away from the mid-line Toward the mid-line, middle, away from the side Toward the front Toward the back, toward the tail Involving both sides of the body Involving one side of the body On the same side of the body On opposite sides of the body Relating to a body cavity wall Relating to organs within body cavities Around a central axis Between two structures Radiology Guidelines and Terms: Separate Procedure However, when a procedure or service that is designated as a ‘separate procedure’ is carried out independently or considered to be unrelated or distinct from other procedures/services provided at the time, it may be reported by itself, or in addition to other procedures/services by appending modifier 59 to the specific ‘separate procedure’ code to indicate that the procedure is not considered to be a component of another procedure, but is distinct, independent procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injury).