Anesthesia Coding Alert

Question: A patient with a stab wound to the right chest wall (with hemopneumothorax) was taken to the OR and the CRNA assumed care (start time 0227). The planned procedure was a thoracotomy, but within five minutes the patient coded and expired a short time later (end time 0252). General anesthesia was never initiated, and the surgeon never made an incision. I would appreciate any help in finding the appropriate way to code this. What do you recommend?

New Jersey Subscriber

Answer: Look at the documentation. You will likely see the anesthesia record looks very similar to anesthesia records you are used to seeing. If that is the case, start time is 2:27 and the end time is either 2:52 or a later time if the patient’s organs were kept viable for donation purposes. The certified registered nurse anesthetist (CRNA) is not required to initiate general anesthesia if she is face-to-face with the patient and providing their service. She would have begun monitoring the patient at the time she assumed care and may have given drugs to keep the patient in a pain-free state while the team was trying to rescue the patient. You will report anesthesia for the thoracotomy with either 00540 (Anesthesia for thoracotomy procedures involving lungs, pleura, diaphragm, and mediastinum (including surgical thoracoscopy); not otherwise specified) or 00541 (… utilizing 1 lung ventilation) if one lung ventilation was performed, as it was the planned surgery.

If the anesthesia record is not completed with any monitoring or drug notations, report 01999 (Unlisted anesthesia procedure(s)) and send a copy of the documentation with the claim.