Introduction
Anesthesia codes are grouped anatomically, beginning with the head. Many anesthesia codes indicate “not otherwise specified.” This allows the code to be reported for the anatomic area, unless a more specific code exists. For example, code 00920 describes anesthesia for procedures on male genitalia (including open urethral procedures); not otherwise specified.
Selecting an anesthesia code follows the same basic steps as assigning procedure codes for other specialties. Coders either look for the Anesthesia in the CPT®Index to locate the correct anatomic area or turn to the Anesthesia 00100-01999 section in CPT and look under the appropriate anatomic heading.
Until the new anesthesia coder becomes familiar with anesthesia codes, it is best to use the Anesthesia section to learn this area of coding. Keep in mind, codes are not always found under the surgical description. For example, the code ranges for anesthesia for a simple mastectomy are not listed under mastectomy, but under breast.
Testing Technique: Although the liver is in the upper right quadrant of the abdomen, the harvesting of a liver is reported with code 01990 Physiological support for harvesting of organ(s) from a brain-dead patient, which is listed under “Other procedures.”
Anesthesia crosswalk books assist coders by crosswalking the known surgical code to an appropriate anesthesia code. When more than one code is suggested by the crosswalk, the coder must determine the most applicable code to report.
Types of Anesthesia
There are three primary types of anesthesia: General, Regional, and Monitored Anesthesia Care (MAC):
General Anesthesia—Affects the brain causing a state of unconsciousness produced by anesthetic agents.
Regional Anesthesia—Loss of nerve sensation in a region of the body by injecting anesthetic agent, using a technique such as:
- Spinal anesthesia: injected beneath the membrane of the spinal cord (subarachnoid, also known as intrathecal)
- Epidural anesthesia: injected into epidural space
- Nerve block or local nerve block: injected around nerves surrounding the operative field
Monitored Anesthesia Care—Anesthesia service where the patient is under a 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.
Testing Technique: Local anesthesia is not reported using anesthesia codes. Local anesthesia is included in the surgical package and not reported separately.
Anesthesia Providers
The anesthesiologist is a physician licensed to practice medicine and who has completed an accredited anesthesiology program. These physicians may personally perform, medically direct, or medically supervise members of an anesthesia care team.
A certified registered nurse anesthetist (CRNA) is a registered nurse who has completed an accredited nurse anesthetist training program. The CRNA may be either medically directed by an anesthesiologist or non-medically directed.
An anesthesiologist assistant (AA) is a healthcare professional who has completed an accredited Anesthesia Assistant training program. The AA may only be medically directed by an anesthesiologist.
An anesthesia resident is a physician who has completed his medical degree and is in a residency program specifically for anesthesiology training.
A student registered nurse anesthetist (SRNA) is a registered nurse training in an accredited nurse anesthetist program.
Anesthesia Coding Terminology
One-Lung Ventilation (OLV)—One lung is ventilated, and the other is collapsed temporarily to improve surgical access in the thoracic cavity. Several anesthesia codes separately identify utilization of one-lung ventilation.
Pump Oxygenator—A cardiopulmonary bypass (CPB) machine is used to function as the heart and lungs during heart or great vessel surgery or other situations.
Intraperitoneal—Within the peritoneal cavity; organs in the upper abdomen include the stomach, liver, gallbladder, spleen, jejunum, ascending, and transverse colon. Intraperitoneal organs in the lower abdomen include the appendix, cecum, ileum, and sigmoid colon.
Extraperitoneal or Retroperitoneal—Indicates outside or behind the peritoneum or peritoneal cavity. Extraperitoneal organs in the lower abdomen include the ureter and urinary bladder. The kidneys and adrenal glands and lower esophagus are extraperitoneal organs of the upper abdomen. Also located in the retroperitoneum are the aorta and inferior vena cava. The appendix and colon are examples of intraperitoneal organs.
Radical—Extensive and complex surgery intended to correct a severe health threat such as cancer.
Diagnostic or Surgical Arthroscopic Procedures—Performed on the temporomandibular joint, shoulder, elbow, wrist, hip, knee, and ankle. Coders assign a diagnostic code only if no surgical procedure is performed (e.g., if a knee arthroscopy is listed as diagnostic). If a meniscectomy is performed, a surgical arthroscopic code is assigned.
Postoperative Pain Management
Postoperative pain management may be requested by the surgeon and billed separately by the anesthesiologist if anesthesia for the surgical procedure is not dependent on the efficacy of the regional anesthetic technique.
Nerve block codes, for example 64415 (brachial plexus block), are reported with general anesthesia if placement is exclusively for postoperative pain management, not for the surgery. Nerve block codes are not reported separately if the block is the mode of anesthesia for a procedure being performed. For example, if a carpal tunnel procedure is performed with an axillary block, a code from the anesthesia section (01810 + related anesthesia time) is reported. No separate code is reported for the axillary block.
Coding depends on the medication injected, the site of the injection, and placement of either a single injection block or a continuous block by catheter. The CPT®code reported is appended with modifier 59 Distinct procedural services to signify the service is separate and distinct from the anesthesia care provided for the surgery.
When ultrasound or fluoroscopic guidance is utilized for pain management procedures and appropriately documented, codes are reported separately with modifier 26 Professional component, unless the code selected includes image guidance (fluoroscopy, ultrasound, or CT).
Acute pain diagnosis codes are separately identified in category G89 of the ICD-10-CM code book.
Continuous catheter codes, for example 64448 Injection(s), anesthetic agent(s) and/or steroid; femoral nerve, continuous infusion by catheter (including catheter placement), are 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 in 64448.
Code 01996 Daily hospital management of epidural or subarachnoid continuous drug administration is assigned for daily hospital management of epidural or subarachnoid continuous drug administration. Continuous infusion by catheter, such as femoral (64448) or sciatic nerve (64446), is not an epidural catheter; therefore, 01996 is not reported with these codes. Anesthesiologists report an appropriate E/M service to re-evaluate postoperative pain if documentation supports the level of service reported and billed.
As with the nerve blocks, the epidural/subarachnoid injection is either a single injection or a continuous catheter. For example, a continuous infusion in the cervical or thoracic area is reported as 62324 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, interlaminar epidural or subarachnoid; cervical or thoracic, without imaging guidance. When these techniques are used for postoperative pain management, the same rules apply.
When an epidural or subarachnoid catheter is placed for a laboring patient, injection codes typically are not reported. CPT® codes to describe labor epidural/subarachnoid services are listed under the Anesthesia for Obstetrics subsection.
Daily hospital management of continuous epidural or subarachnoid drug administration (01996) cannot be reported on the day of the epidural or subarachnoid catheter placement. It may be reported starting with the first postoperative day.
ICD-10-CM Coding
The majority of anesthesia services are provided to patients during surgery. The postoperative diagnosis is coded because the preoperative diagnosis may change intra-operatively. For example, if a patient is admitted with pain in the right lower quadrant and subsequently has an appendectomy, the postoperative diagnosis may be acute appendicitis.
Supporting diagnosis codes are reported if relevant to either substantiate medical necessity or support physical status modifiers, which will be discussed in the next section.
With few exceptions, diagnosis codes for anesthesia are assigned in the same manner as any other diagnosis:
- Identify reason for anesthesia service
- Review for other pertinent information and supporting diagnosis codes
- Check the Index to Diseases and Injuries and then check the code in the Tabular List
- Locate main entry term
- Pay attention to notes listed in main terms
- Understand coding conventions (See ICD-10-CM Official Guidelines for Coding and Reporting)
- Look for additional instructions in the Tabular (numeric) List
- Code to highest level of specificity
- Assign pertinent related ICD-10-CM code(s)
CPT Coding
Services included with the base unit value of anesthesia codes reported are:
- All usual preoperative and postoperative visits
- Anesthesia care during the procedure
- Administration of fluids and/or blood products during the surgery
- Non-invasive monitoring (ECG, temperature, blood pressure, pulse oximetry, capnography, and mass spectrometry)
Unusual forms of monitoring — for example, arterial lines, central venous (CV) catheters, and pulmonary artery catheters (e.g., Swan Ganz) — are not included in the base unit value of the anesthesia code.
Base unit values are not listed separately in CPT®. The American Society of Anesthesiologists (ASA) determines the base unit values for anesthesia codes, based on the difficulty of the procedure performed. The ASA and Medicare each publish a list of base unit values.
Determining the base value is the first step in calculating anesthesia charges and payment expected. Time reporting is the second step.
Anesthesia time begins when the anesthesiologist begins to prepare the patient for anesthesia in either the operating room or an equivalent area. Pre-anesthesia assessment time is not part of reportable anesthesia time. Anesthesia time ends when the anesthesiologist is no longer in personal attendance, and generally is reported when the patient is safely placed under postoperative supervision.
Time does not need to be continuous. For example, an axillary block may be performed in a holding room, prior to surgery. If the axillary block is the mode of anesthesia, then the time for placement of that block is counted. The anesthesiologist may then leave, and when the patient is brought to the operating room, and the anesthesiologist again counts anesthesia time. The time for the block is then added to the total anesthesia time for the case.
Time reporting on claims may vary, and there is no national guideline. Time units are added to the base unit value as is customary in the local area.
Medicare requires exact time reporting without rounding to the nearest five minutes. For example, if anesthesia time starts at 11:02 and the patient is turned over to PACU at 11:59, the reported anesthesia time is 57 minutes. Medicare divides the 57 minutes by 15-minute increments for a total value of 3.8 units. If the procedure has a base value of six units, adding 3.8 units gives a total of 9.8 units, which is then multiplied by the Anesthesia Conversion Factor for the geographic location where the services are provided.
Other insurance companies may process the anesthesia time reported in increments — from exact time (like Medicare), to 10, 12, and 15 minutes, or some other time increment.
Multiple (surgical) procedures may be performed on one patient during anesthesia administration. When this occurs, the surgery representing the most complex procedure is reported because this service carries a higher base unit value. Anesthesia time is reported as usual, from the time the anesthesiologist begins to prepare the patient until the patient is safely placed under postoperative supervision.
Testing Technique: The surgical time does not play a role in determining the anesthesia time.
EXAMPLE
A patient has an inguinal hernia repair (00830, base 4) and a ventral hernia repair (00832, base 6) — only the ventral herniorrhaphy (00832) is reported because it is more complex and has a higher base value than the inguinal hernia surgery. The total time for both procedures is reported as anesthesia time. The diagnosis code related to the ventral hernia is reported in the primary position. Reporting the inguinal hernia diagnosis as secondary helps explain why the reported anesthesia time is longer than normally expected for the procedure reported.
Only one anesthesia code is reported during anesthesia administration, except in the case where there is an anesthesia add-on code. For example, the anesthesia section of CPT® has add-on codes listed under Burn Excision or Debridement and Obstetric. These add-on procedures may not be reported alone; they must be reported with the applicable primary anesthesia code referenced in parentheses.
For example, add-on code +01953 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; each additional 9% total body surface area or part thereof (List separately in addition to code for primary procedure) is reported if the total body surface area (TBSA) treated during surgery exceeds 9 percent. This add-on code is reported in addition to 01952 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; between 4% and 9% of total body surface area for each additional 9% or part thereof of the TBSA treated. Therefore, a TBSA of 40% is reported as follows:
| 01952 + Time units | First 4 to 9% of TBSA |
| +01953 x 4 | Represents the remaining 31% of TBSA in increments of 9% (the remaining 4% 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.
Physical Status Modifiers
Physical status modifiers are anesthesia modifiers describing the physical status of the patient. These modifiers are not recognized by Medicare for additional payment, and no base values are listed in CPT®. Because insurance companies are familiar with anesthesia coding guidelines in CPT®, non-Medicare payers typically pay additional base units.
The following modifiers are assigned to patients based on their individual physical status:
- P1—A normal healthy patient—No extra value added
- P2—A patient with mild systemic disease—No extra value added
- P3—A patient with severe systemic disease—1 extra unit
- P4—A patient with severe systemic disease that is a constant threat to life—2 extra units
- P5—A moribund patient who is not expected to survive without the operation—3 extra units
- P6—A declared brain-dead patient whose organs are being removed for donor purposes—No extra value added
Eg: A patient has hypertension. Append modifier P2 (Systemic disease is not stated as uncontrolled)
A patient has uncontrolled DM – Append modifier P3 (Due to the severe systemic disease)
A patient met with an accident and is dead on arrival to the hospital – Append modifier P6 (is an organ donor)
Example: a non-Medicare patient has a severe systemic disease, which is a constant threat to life and is undergoing a direct coronary artery bypass graft (CABG) with a pump oxygenator is reported as 00567-P4.
Qualifying Circumstances
Qualifying circumstances (QC) are anesthesia add-on codes assigned to report anesthesia services performed under difficult circumstances significantly affecting the character of an anesthesia service. AMA assigns base unit values for the qualifying circumstances. The base values are not listed in CPT®. These add- on codes are not recognized by Medicare for additional payment.
+99100—Anesthesia for patient of extreme age, younger than one (1) year and older than 70—1 extra unit
+99116—Anesthesia complicated by utilization of total body hypothermia—5 extra units
+99135—Anesthesia complicated by utilization of controlled hypotension—5 extra units
+99140—Anesthesia complicated by emergency conditions (specify)—2 extra units
Documentation must support the qualifying circumstance code(s) reported. An emergency is defined as existing when a delay in the treatment of the patient would lead to a significant increase in a threat to the patient’s life or body parts.
— Anesthesia is a state of temporary induced (Drug/Gas) loss of sensation or awareness. The CPT code range from 00100 – 01999 plus “Anesthesia modifier”.
— An Anesthesiologist, Anesthesia assistant or qualified non-physician anesthetist can provide Anesthesia service.
Anesthesia coding Guidelines:
— Select the appropriate CPT code for the surgical procedure performed, and then select the appropriate ASA- American Society of Anesthesiology crosswalk code.
— Select the appropriate modifier to identify the anesthesia provider.
— Assign the appropriate Physical status modifier
— Assign the appropriate qualifying circumstances codes if applicable.
Multiple procedures at the same session:
If multiple surgical procedures are performed during a single anesthesia administration, the total time spent for all procedures would be considered for Anesthesia Time unit.
Anesthesia Time Unit:
1. Start Time: The anesthesiologist begins to prepare the patient for the induction of anesthesia in the operating room. (Note: reviewing Medical Record before surgery is not considered)
2. End Time: The anesthesiologist is no longer in personal attendance; the patient may be safely placed under postoperative supervision.
Time of anesthesia is calculated in units (Each 15 min = 1 unit)
Total anesthesia time should be recorded in minutes. Each 15 min is equal to one unit
Discontinuous Time
There may be some interruptions in anesthesia care during a procedure; if the provider is no longer personally attending the patient should be recorded correctly about the interrupted timings.
Eg: The anesthesiologist begins care at 9.00, care interrupted at 9.25 (25 minutes) and resumes care at 9.30 ending care at 9.55 (25 minutes), there would be 50 minutes of anesthesia time.
Anesthesia Modifiers:
47: For Surgeon: When Surgeon gives the anesthesia need to use modifier 47(Anesthesia by surgeon) with the procedure code of Surgery. Do not utilize 00000 (anesthesia) series codes.
For Anesthesiologist
1. AA: Anesthesia services performed personally by anesthesiologist (or) an anesthetist assists a physician in the care of a single patient. (Anesthesia by Anesthesiologist)
2. QY: Medical direction of one Qualified Non-physician(CRNA)
3. QK: Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals.(CRNA)
4. AD: Medical supervision by a physician: more than four concurrent anesthesia procedures.(CRNA)
For Non-physician Anesthetist
1. QX: Qualified Non-physician Anesthetist service: with medical direction by a physician. (CRNA with Physician supervision)
2. QZ: Qualified Non-physician Anesthetist service: without medical direction by a physician. (Only CRNA without supervision)
For MAC (Monitored Anesthesia Care)
1. QS: MAC (Can be billed by Qualified Non-physician Anesthetist / Anesthesia Assistant/physician)
2. G8: MAC for deep complex or complicated / markedly invasive surgical procedure
3. G9: MAC for a patient who has severe cardiopulmonary conditions
Billing Guidelines: Except Medicare all other insurance allow physical status modifiers to receive additional total units of anesthesia service reported for patients.
Important Abbreviations:
CRNA: Certified registered nurse anesthelogist
SRNA: Student registered nurse anesthetist
MAC: Monitored anesthesia care
- A healthy 79-year-old male patient with communicating hydrocephalus undergoes creation of a ventriculoperitoneal shunt. What is the correct anesthesia code selection for this procedure?
A.00220-P1, 99100
B.00220-P1
C.00210-P1
D.00210-P1, 99100
- A healthy 32 year old with a closed distal radius fracture received monitored anesthesia care for an ORIF of the distal radius. What is the code for the anesthesia service?
A.01830-P1
B.01860-QS-P1
C.01830-QS-P1
D.01860-QS-G9-P1
- A 10-month-old child is taken to the operating room for removal of a laryngeal mass. What is the correct coding for the anesthesia service?
A.00320
B.00326
C.00320, 99100
D.00326, 99100
Case 1:
Anes Start: 7:50Anes End: 16:54
Anesthesiology: DD, MD CRNA: JS, CRNA
Physical Status Modifier: P3
Attending was immediately available, present at all critical points, present during positioning, present at induction, reviewed patient chart and performed the preoperative assessment. Dr. D was medically directing two other anesthesia cases during this case.
Dr. D performed placement of the A-line and CVP. After the area was prepped and draped, Dr. D inserted the arterial line in the right radial artery. The line was secured with tape. Dr. D also inserted the central line in the right internal jugular vein of this 56-year-old patient.
Operative Report
Preoperative Diagnosis:
Primary pancreatic neoplasm of the head of the pancreas
Postoperative Diagnosis:
1. Adenocarcinoma of the uncinate process of the pancreas
2. Liver cirrhosis
3. Pancreatitis
Procedure:
1. Pyloric-sparing Whipple procedure
2. Liver wedge biopsy
Anesthesia:
General endotracheal anesthesia
What CPT® and ICD-10-CM codes are reported for the anesthesiologist and the CRNA?