Anesthesia Coding Alert

Question: An anesthesiologist at our facility spent about 20 minutes on the pre-anesthesia exam, then the surgery was cancelled. The payer is Medicare. How should we code to appropriately cover this scenario?

Wyoming Subscriber

Answer: A choice from hospital care evaluation and management (E/M) codes 99231-99233 will appropriately cover this situation. The code selection will be based on the pre-anesthesia documentation. The descriptor codes are as follows:

• 99231 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: a problem focused interval history; a problem focused examination; medical decision making that is straightforward or of low complexity...)
• 99232 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: an expanded problem focused interval history; an expanded problem focused examination; medical decision making of moderate complexity...)
• 99233 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: a detailed interval history; a detailed examination; medical decision making of high complexity...)