Anesthesia Coding Alert

Question: I have several questions about when our anesthesiologist provides moderate sedation during radiology procedures.

• I know that it’s permissible to capture any diagnoses found in the anesthesia record during surgeries, but is that still true for radiology? Can we capture any diagnoses found in the radiology report supporting the procedure requiring sedation? 
• If capturing these other diagnoses is permissible, what should be the first-listed diagnosis?  What the anesthesiologist says it is, or what the radiologist (physician performing the procedure) says it is? Often times the two are different. 
• Should we code the findings of the radiologist on the moderate sedation case (such as "density in the right lower lobe [of the lung]")?

Arizona Subscriber

Answer: We’ll address each of your questions individually.

• As long as you are able to support where the diagnosis came from and it is accurate, it may be reported. That includes reporting any diagnoses that could help support the need for moderate sedation, even if they’re from the radiologist.
• If the anesthesiologist and radiologist have different diagnoses, the radiologist's choice will override the other. He's the one doing the procedure and could know more about exactly what's going on than the anesthesia provider might.
• The findings of the radiologist are not applicable to the services that anesthesia provided. However, including the radiologist’s findings might help justify the need for anesthesia if the procedure (or a similar one) needs to be performed again.