Anesthesia Coding Alert

Multiple services add base units to complex procedure A reader recently posted the following case study on The Coding Institute's Anesthesia & Pain Management discussion group. Determine how you would code this procedure, then follow our experts' advice to determine all of the codes that your anesthesiologist can bill for this emergency case: Case study: Our physician provided anesthesia during an exploratory laparotomy for a perforated bowel obstruction, and also documented a separate charge for arterial line (A-line) insertion. Later, he initiated positive pressure ventilation (first day). The patient is P3 (A patient with severe systemic disease), and the chart indicates that the case was an emergency because of septic shock. How should I code this?

First step: You should report either 44120 (Enterectomy, resection of small intestine; single resection and anastomosis) or anesthesia code 00790 (Anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; not otherwise specified) for the laparotomy, depending on whether the carrier requires surgical or anesthesia codes.

Next step: CPT's anesthesia guidelines state that traditional anesthesia service does not include unusual forms of monitoring (such as intra-arterial, central venous and Swan-Ganz catheters). You can therefore report 36620 (Arterial catheterization or cannulation for sampling, monitoring or transfusion [separate procedure; percutaneous]) for the A-line insertion and receive 3 more base units. 99140 Adds Two Additional Units Bonus: Based on the patient's physical status (P3), you can also report emergency code +99140 (Anesthesia complicated by emergency conditions [specify]), which adds two units to your claim if your carrier reimburses for the "qualifying circumstances" codes (Medicare does not). CPT defines an emergency as when a treatment delay would lead to a significant increase in the threat to life or body part. Not all carriers reimburse for this add-on code, but you should still report it to code compliantly for statistical data collection and other uses of CPT/ICD-9 codes, says Marvel J. Hammer, RN, CPC, CHCO, owner of MJ Consulting in Denver.

Consider this: Coders' recommendations vary for reporting septic shock. Some experts recommend 569.83 (Perforation of intestine) as the primary diagnosis, with supporting diagnoses such as 560.2 (Intestinal obstruction without mention of hernia; volvulus), 518.5 (Pulmonary insufficiency following trauma and surgery) and 998.0 (Postoperative shock). (The additional diagnoses help justify postoperative ventilation.)

Code 995.92 (Systemic inflammatory response syndrome due to infectious process with organ dysfunction) is another possibility, Hammer says, depending on how much information you have. But you must first code the underlying condition and use an additional code to specify organ dysfunction (such as 785.52, Septic shock) before reporting 995.92.

Don't forget: After you code the procedure itself, you should review the follow-up service of initiating positive pressure ventilation. Before coding this ventilation management, first verify when "later" was -- [...]