Anesthesia Coding Alert

Question: Our anesthesiologist used active warming to keep the patient’s body temperature measurement equal to or greater than 96.8 degrees Fahrenheit during surgery. The temperature was taken within the designated timeframe for a general anesthesia case that lasted 47 minutes. Should we report only G9363?Colorado Subscriber

Answer: Yes, you can report G9363 (Duration of monitored anesthesia care [MAC] or peripheral nerve block [PNB] without the use of general anesthesia during an applicable procedure or general or neuraxial anesthesia less than 60 minutes, as documented in the anesthesia record).

Code G9363 applies for all patients, regardless of age, who undergo surgical or therapeutic procedures under general or neuraxial anesthesia lasting 60 minutes or longer. The exception is a patient undergoing cardiopulmonary bypass. Cardiac patients on bypass are an exception because they are intentionally kept cooled down during the surgery to protect their organs.

You can use other measurement codes for patients who meet one of the two following criteria:

• Active warming was used intraoperatively for the purpose of maintaining normothermia; or
• At least one body temperature equal to or greater than 36 degrees Centigrade (or 96.8 degrees Fahrenheit) was recorded within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time.

Remember: The anesthesia time used for this measure should be the time recorded in the anesthesia record. If you aren’t provided with time information, watch for clues that the anesthesiologist used a “Bair Hugger” or other over-the-body active warming device.