Anesthesia Coding Alert

Question: A patient underwent a tracheostomy for chronic respiratory failure with prolonged intubation. About an hour after the procedure, he returned to the operating room because of persistent oozing at the tracheostomy site. The surgeon removed the tracheostomy tube. He then explored the tracheostomy site, stopped the bleeding and changed the tracheostomy tube. How should I code anesthesia for these two encounters?

Wisconsin Subscriber
 
Answer: Several years ago, the AMA recommended that if you can't find a code for re-exploration, you should report the same code as the original procedure. In this case, that would be 31600 (Tracheostomy, planned [separate procedure]) for the surgeon, and 00320 (Anesthesia for all procedures on esophagus, thyroid, larynx, trachea and lymphatic system of neck; not otherwise specified, age 1 year or older) for the anesthesiologist.
 
Add modifier -78 (Return to the operating room for a related procedure during the postoperative period) to the second procedure (though remember that some carriers only accept modifier -78 for the surgeon's claims, not the anesthesiologist's; verify the carrier's guidelines before submitting modifier -78).
 
Because both encounters happened on the same day, some coders recommend that you also append modifier -59 (Distinct procedural service) to the second procedure. Report diagnosis codes V45.89 (Other postprocedural status; other), 518.83 (Chronic respiratory failure) and 519.09 (Other tracheostomy complications).  - You Be the Coder and Reader Questions were answered by Tonia Raley, CPC, claims processing manager with Medical Information Management Systems in Phoenix.