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Code: K63.1

Code Name: ICD-10 Code for Perforation of intestine (nontraumatic)

Block: Perforation of intestine (nontraumatic)

Perforation (nontraumatic) of rectum

Excludes 1: perforation (nontraumatic) of duodenum (K26.-)
perforation (nontraumatic) of intestine with diverticular disease (K57.0, K57.2, K57.4, K57.8)

Excludes 2: perforation (nontraumatic) of appendix (K35.2, K35.3)

Details: Other diseases of intestines (K55-K64)

Guidelines: Diseases of the digestive system (K00-K95)

Excludes 2: certain conditions originating in the perinatal period (P04-P96)
certain infectious and parasitic diseases (A00-B99)
complications of pregnancy, childbirth and the puerperium (O00-O9A)
congenital malformations, deformations and chromosomal abnormalities (Q00-Q99)
endocrine, nutritional and metabolic diseases (E00-E88)
injury, poisoning and certain other consequences of external causes (S00-T88)
neoplasms (C00-D49)
symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R94)

For more details on K63.1 , ICD-10 Code for Perforation of intestine (nontraumatic) visit: https://coder.aapc.com/icd-10-codes/

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CANPC Anesthesiology coding essentials for successful anesthesiology coding by Vino C. Mody Jr., M.D., COC, CPC, CCS-P, CANPC, CCVTC
Table of Contents
Preface
Introduction
CPT Coding
Steps for anesthesia coding
Method for anesthesia coding
Types of anesthesia
Local
Monitored anesthesia care (MAC)
Regional
General
Obstetric anesthesia
Daily Hospital Management of Epidural
Trigger Point Injection
Sacroiliac Injection
Discography
Epidurals
Transforaminal epidural
Pain pumps
Facet joint injections
Nerve blocks
Destruction by neurolytic agent
Cases for CANPC simulation (Cases 1-15)
Case number Anesthesia for procedures on (or in)
Case 1 Thoracotomy
Case 2 Integumentary system
Case 3 Arthroscopic on hip joint
Case 4 Intracranial
Case 5 Open or surgical on humeral head and neck
Case 6 Transurethral (including urethrocystoscopy)
Case 7 Intraperitoneal in lower abdomen
Case 8 Lumbar region
Case 9 Integumentary system, muscles and nerves of head, neck, and posterior trunk
Case 10 Integumentary system, muscles and nerves of head, neck, and posterior trunk
Case 11 Lumbar region
Case 12 Integumentary system, muscles and nerves of head, neck, and posterior trunk
Case 13 Integumentary system on the extremities, anterior trunk, and perineum
Case 14 Intraoral
Case 15 Nose and accessory sinuses
Case 16 Upper gastrointestinal, endoscope introduced proximal to duodenum
Case 17 Male genitalia (including open urethral procedures); vasectomy
Case 18 Open or surgical arthroscopic on knee joint
Case 19 Eye; lens surgery
Case 20 Transurethral (including cystoscopy); transurethral resection of bladder tumors(s)
Case 21 Integumentary system, muscles and nerves of head, neck, and posterior trunk
Case 22 Integumentary system on the extremities, anterior trunk and perineum
Case 23 Hernia repairs in upper abdomen; lumbar and ventral (incisional) hernias and/or wound
dehiscence
Case 24 Electrophysiologic including radiofrequency ablation
Case 25 Intraperitoneal in upper abdomen including laparoscopy
Case 26 Integumentary system, muscles and nerves of head, neck, and posterior trunk
Case 27 Percutaneous image guided on the spine and spinal cord; therapeutic
Case 28 Partial rib resection
Case 29 Upper gastrointestinal endoscopic
Case 30 Lumbar region
Case 31 Upper abdomen including laparoscopy
Case 32 Intraperitoneal in upper abdomen
Case 33 Esophagus
Case 34 Therapeutic interventional radiological involving the arterial system; carotid or coronary
Case 35 Open on bones of lower leg, ankle, and foot; osteotomy or osteoplasty
Case 36 Intracranial
Case 37 Heart, pericardial sac, and great vessels of chest; with pump
Case 38 Thoracic spine and cord, via an anterior transthoracic approach; utilizing 1 lung ventilation
Case 39 Intraperitoneal in lower abdomen including laparoscopy
Case 40 Second- and third-degree burn excision or debridement with or without skin grafting , any site, for total body surface area (TBSA) treated during anesthesia or surgery; less than 4% total body surface area
Case 41 Heart, pericardial sac, and great vessels of chest; with pump oxygenator, younger than 1 year of age
Case 42 Heart, pericardial sac, and great vessels of chest with pump oxygenator, age 1 year or older, for all non-coronary bypass procedures
Case 43 Direct coronary artery bypass grafting; with pump oxygenator
Case 44 Non-invasive imaging
Case 45 Vaginal (including biopsy of labia, vagina, cervix, or endometrium); vaginal hysterectomy
Case 46 Open or surgical arthroscopic on humeral head and neck, sternoclavicular joint, acromioclavicular joint, and shoulder joint
Case 47 Open or surgical arthroscopic on humeral head and neck
Case 48 Percutaneous image guided on spine and spinal cord; therapeutic
Case 49 Integumentary system on the extremities, anterior trunk and perineum; radical or modified radical on the breast
Case 50 External, middle, and inner ear including biopsy
Case 51 Intraperitoneal in lower abdomen including laparoscopy
Case 52 Integumentary system on the extremities, anterior trunk, and perineum
Case 53 Esophagus, thyroid, larynx, trachea and lymphatic system of neck; age 1 year and older
Case 54 Integumentary system, muscles and nerves of head, neck, and posterior trunk
Case 55 Hernia repairs in lower abdomen
Case 56 Intraperitoneal in upper abdomen including laparoscopy
Case 57 Intraperitoneal in upper abdomen including laparoscopy; gastric restrictive for morbid
obesity
Case 58 Nerves, muscles, tendons, fascia, and bursae of shoulder and axilla
Case 59 Intraperitoneal in upper abdomen including laparoscopy
Case 60 Access to central venous circulation
Case 61 Lower intestinal endocscopic, endoscope introduced distal to the duodenum
Case 62 Integumentary system on the extremities, anterior trunk, and perineum
Case 63 Vascular shunt, or shunt revision, any type (e.g. dialysis); Injection, anesthetic agent,
suprascapular nerve
Case 64 Integumentary system, muscles and nerves of head, neck, and posterior trunk
Case 65 Upper gastrointestinal endoscopic, endoscope introduced proximal to duodenum
Case 66 Extraperitoneal in lower abdomen, including urinary tract; adrenalectomy
Case 67 Upper gastrointestinal endoscopic, endoscope introduced proximal to duodenum
Case 68 Anorectal
Case 69 Lower intestinal endoscopic, endoscope introduced distal to duodenum
Case 70 Intraperitoneal in upper abdomen including laparoscopy














Preface
The coding material is borrowed from AHA Coding Clinic subscriptions for ICD-10-CM/PCS and HCPCS 2000-2016, Practicode Practicums, Exams, Optum 360 ID-10-CM Coding Workbook for General Surgery 2016, Maxim Assessment 2016, and Healthcare Business Monthly from American Academy of Professional Coders. Merriam Webster’s Medical Desk Dictionary 2005 was the resource used for definitions.
CPT, HCPCS II, and ICD-10-CM books are required for the medical coding.
ASA (American Society of Anesthesiologists) Crosswalk and ASA Relative value guide are essential for successful anesthesiology coding. 2015 ASA Crosswalk and 2015 ASA Relative Value Guide were used to determine the codes for this book.
ASA Relative Value Guide is in addition required for anesthesiology coding.
Introduction
The first 15 cases highlight principles outlined in Study Guide for CANPC 2014/2016 for full anesthesiology coding according to American Academy of Professional Coders. The book covers anesthesiology and pain management coding to generate the correct overall anesthesiology code for the case and to learn pain management coding. Clinical viewpoint covers the rationale for case.
This book will help you prepare for CANPC examination in conjunction with reading the literature available in Study Guide for CANPC 2016 for preparation. It highlights the correct method for anesthesiology coding for success on CANPC exam by American Academy of Professional Coders and gives you practice. Knowing how to perform anesthesiology coding is imperative for passing the exam. For the exam, MD means medical doctor and CRNA means Certified registered nurse anesthetist. Pain management coding is in addition covered.
For CANPC exam, if you code for a different CPT answer, still perform the ASA Crosswalk Lookup on your selected CPT codes. This will help you answer the anesthesiology code correctly.
CPT Coding
Steps for anesthesia coding
Determine the appropriate anesthesia code for the surgical procedures provided utilizing ASA Crosswalk Lookup
For example, the corresponding anesthesia code for CPT code 66984 Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique is 00142 Anesthesia for procedures on eye; lens surgery. CPT code=base value units=(corresponding) anesthesia code
66984=4 base value units=00142
See method for anesthesiology coding outlined later in this introduction
For two or more CPT codes, select the overall anesthesia code with highest base value units. For a tie, select the anesthesia code corresponding with the first-listed CPT code.
Assign modifiers to identify the anesthesia provider
The modifiers for the provider can be for either the anesthesiologist (or doctor) or CRNA(s). It is important to distinguish between [Anesthesiologist or Doctor] and CRNA modifier codes. [Anesthesiologist or Doctor] codes are for the billing anesthesiologist and [CRNA] codes are for the billing CRNA.
See the table in HCPCS II.
AA [Anesthesiologist] Anesthesia services performed personally by anesthesiologist
AD [Anesthesiologist] Medical supervision by a physican; more than four concurrent anesthesia procedures [more than 4 CRNAs is included here]
QK [Doctor] Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals [2, 3, or 4 CRNAs is included here]
QS Monitored anesthesia care (MAC) service
QX [CRNA] CRNA service: with medical direction by a physician
QY [Doctor] Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist
QZ [CRNA] CRNA service: without medical direction by a physician
Report physical status modifiers for anesthesia services
PS I through PS VI can be found in the Relative value guide. The base units for each physical status are important in the units calculation for PS or physical status. PS with corresponding base units value are listed.
P1 A normal healthy patient= 0
P2 A patient with mild systemic disease= 0
P3 A patient with severe systemic disease= 1
P4 A patient with severe systemic disease that is a constant threat to life= 2
P5 A moribund patient who is not expected to survive without the operation= 3
P6 A declared brain-dead patient whose organs are being removed for donor purposes= 0
Report qualifying circumstance codes when appropriate
I call qualifying circumstances codes by the heading Emergency
Qualifying circumstances with base unit values
+99100 Anesthesia for patient of extreme age, younger than 1 year and older than 70= 1
+99116 Anesthesia complicated by utilization of total body hypothermia= 5
+99135 Anesthesia complicated by utilization of controlled hypotension= 5
+99140 Anesthesia complicated by emergency conditions= 2
Code additional procedures performed by the anesthesia provider. To count as a separately reportable code on the anesthesiology service, the anesthesia provider has to perform the additional procedures, not the surgeon.
The following procedures are separately reported for the anesthesiology service if performed by the anesthesiology provider (Anesthesiologist or Doctor or CRNA)
Insertion of central venous catheters, 36555 or 36556
Insertion of arterial catheters, 36620 or 36625
Insertion of Swan Ganz catheter, 93503
Transesophageal echocardiogram (TEE), 93312
Determine the total units for anesthesia services
For units calculation, I use:
Units=Base+Time+PS+Emergency
Base units (for the anesthesia code), time units (anesthesia time/15), PS (physical status modifier units), and Emergency (Qualifying circumstances units) are added together to generate the total units.
Medicare units=Base+Time (For a Medicare patient)
Method for anesthesiology coding
Anesthesiology coding
To determine the overall anesthesia code for the case, look up each CPT code in the ASA (American Society of Anesthesiologists) Crosswalk and note the corresponding anesthesiology code with base unit value. The anesthesiology code with the highest base unit value is the overall anesthesia code for the case for all CPT procedures.
Example:
Anesthesia services provided by anesthesiologist (PS III)
Arstasis: Introduce access device for self-sealing arteriotomy; Enlarged aneurysm area near the anastomosis to the brachial artery, excise the AV fistula
CPT and ICD-10-CM codes:
35011, 35206, 37607, I71.2
Corresponding anesthesia codes with base unit values and CPT codes
ASA Crosswalk Lookup
35011=10 base value units=01652
35206=4 base value units=01782
37607=6 base value units=01840
Overall anesthesia code for the case (choose the anesthesia code with the highest base value units; first listed code splits a tie)
01652-AA-P3
Vino C. Mody Jr., M.D., COC, CPC, CCS-P, CANPC, CCVTC
Types of anesthesia
Local
Local anesthesia is bundled with the minor surgery CPT code
Monitored anesthesia care (MAC)
Deep sedation in which the patient can respond to painful stimuli but maintains control of the airway
Regional
Epidurals and nerve blocks
General
The patient is unconscious and has no control of the airway
Services included in the anesthesia code for general anesthesia, MAC, or regional anesthesia
Pre-operative visits, post-operative visits, patient care during the procedure, administration of fluids and blood, EKGs, temperature measurement, blood pressures, intubation, laryngoscopy, introduction of a needle or catheter, venipuncture, blood transfusions, blood sample procurement through an existing line, temporary transcutaneous pacemakers, and injections of diagnostic or therapeutic substances.
Obstetric anesthesia
When selecting a code, see if the patient received neuraxial labor analgesia prior to delivery for pain control and anesthesia. Report 01967 for Neuraxial labor analgesia/anesthesia for planned vaginal delivery including any repeat subarachnoid needle placement and drug injection and any necessary replacement of an epidural catheter during labor.
Daily Hospital Management of Epidural
Reported starting with the first post-operative day (01996) and not on the day of the epidural or subarachnoid catheter placement.
Trigger point injections
Counted based on the number of muscles injected, not the number of injections (20552)
Sacroiliac injection
Sacroiliac injection of anesthetic or steroid utilizing CT or fluoroscopy imaging guidance is included in 27096.
Discography
Discography (62290 or 62291) combined with radiological supervision and interpretation (72285 or 72295) is performed with contrast injected into the disc.
Epidurals
Single injection not via indwelling catheter (62310 or 62311)
Injection including catheter placement for continuous infusion of intermittent bolus (62318 or 62319)
When the epidural is the method for the anesthesia, code the appropriate anesthesia code (00100-01999)
Transforaminal epidural
CPT codes are based on the number of levels and region of the spine and performed for diagnostic and therapeutic purposes.
The procedure (64479 -64484) can identify which nerve is causing the pain and can be performed for chronic pain.
If the provider performs ultrasound guidance, code Category III codes (0228T or 0229T; 0230T or 0231T)
Pain pumps
Procedures with pain pumps are used for pain management are reported with codes 62350-62370.
When an intrathecal (involves penetration of the dural membrane) or epidural (does not penetrate the dura) catheter is connected to an implantable infusion pump (IIP), code 62350 or 62351.
Programmable infusion pumps (PIIP) and IIPs are important for drug delivery systems and for treatment of a wide range of clinical conditions such as cancer therapy and chronic pain therapy.
Facet joint injections
Facet joint injections temporarily relieve pain by filling the facet joint with an anesthetic medication that numbs the facet joint with an anesthetic medication that numbs the facet joint, ligaments, and joint capsule around the facet joint.
Facet joint injections are coded by 64490, 64491, 64492, 64493, 64494, or 64495 depending on the level of the injection.
Nerve blocks
A nerve block is an injection of an anesthetic agent directly (64400-64455) near a nerve to stop pain. When a nerve block is performed for regional anesthesia, report the appropriate anesthesia code (00100-01999).
Destruction by neurolytic agent
Neurolytic agents destroy nerve tissue (64600-64640) for ongoing relief of pain for weeks or up to a year due to disease or other abnormality of the nerve root. This procedure is known as a rhizotomy.
Cases for CANPC exam simulation
Case 1
Anesthesia time: 08:00 A.M. to 2:00 P.M.
Dr. SC, MD, anesthesiologist performed anesthesiology for the case
A right radial arterial catheter, central venous catheter, and Swan Ganz catheter were placed by Dr. SC at the beginning of the case
Anesthesiologist performed general endotracheal anesthesia
PS III
Pt. is 71 year old male with multiple medical problems, COPD, hypertension, hypercholesterolemia, and type 2 diabetes mellitus, who presents with difficulty breathing.
Diagnosis: Chronic pneumothorax
Procedures: Surgical thoracoscopy with therapeutic wedge resection and mechanical pleurodesis
Codes
J93.81, J44.9, E78.0, I10, E11.9, 32666, 32650
Pleurodesis is surgical fusion of the pleura.
ASA Crosswalk Lookup; CPT Code=Base value units=Anesthesiology code
32666=15 base value units=00541
32650=12 base value units=00540
Overall anesthesiology code for the case
00541-AA-P3, +99100
36620, 36556, 93503
00541-AA=Anesthesia for thoracotomy procedures involving lungs, pleura, diaphragm, and mediastinum (including surgical thoracoscopy), utilizing 1 lung ventilation
00541 anesthesiology code has higher base value units than 00540
AA Anesthesiologist performed the anesthesia for the case
PS3=Physical status modifier III
+99100 Anesthesia for patient of extreme age, younger than 1 year and older than 70
Since Dr. SC, the anesthesiologist placed the right radial arterial catheter at the beginning of the case, the code for the arterial catheterization is coded separately
Since Dr. SC, the anesthesiologist placed the central venous catheter at the beginning of the case, the code for the central venous catheterization is coded separately
Since Dr. SC, the anesthesiologist placed the Swan Ganz catheter at the beginning of the case, the code for the placement of the Swan Ganz catheter is coded separately
Total units=Base+time+PS+Emergency=
=15+24.0+1+1=41.0
Case 2
Anesthesia time: 09:00 A.M. to 1:20 P.M.
Dr. DM, MD anesthesiologist performed anesthesiology for the case supervising 1 CRNA
CRNA service: JS
Anesthesiologist placed central venous catheter and Swan Ganz catheter
Anesthesia: General endotracheal
Anesthesiologist noted emergency condition: bleeding during surgery
Pt. is 20 year old female with no medical problems
PS I
Diagnosis: Partial amputation of left middle finger cutting across the finger in an edger in a garden
Procedures:
Full thickness graft with closure of donor site, hand, 2.0 cm X 2.0 cm
Adjacent tissue transfer, left hand, defect 0.5 cm X 0.5 cm
Excisional debridement of skin and subcutaneous tissues of left middle finger
Codes
S68.623A, W29.3, Y92.007, 15240, 14040-51, F2, 11010-51
ASA Crosswalk lookup
15240=5 base value units=00300
14040=5 base value units=00300
11010=3 base value units=00400
Overall anesthesia code for the case for the billing anesthesiologist
00300-QY-P1 +99140,
36556, 93503
0300 has highest base unit value
For a tie of highest base unit value, the anesthesia code corresponding to the first listed CPT code for the case. In this case, both anesthesia codes are the same for the highest base value units
QY The anesthesiologist directed one CRNA; this is an anesthesiologist’s code
P1 The patient is a normal healthy patient
Overall anesthesia code for the case for the billing CRNA
0300-QX-P1, +99140
Total Units=Base+Time+PS+Emergency=5+17.3+0+2=24.3 (Can round up or down)
If the patient were a Medicare patient,
Medicare Total Units=Base+Time=5+17.3=22.3
Case 3
Anesthesia time 07:45 A.M to 11:00 A.M.
Anesthesiologist, DD, MD medically directing two CRNAs
CRNAs, JM, PS
Anesthesia: Monitored anesthesia care (MAC)
PS III
60 year old female with pain on right hip while walking. Pain on movement of right hip.
Diagnoses: Osteoarthritis of the right hip, chondrocalcinosis of right hip, articular cartilage disorder of right hip
Procedures: Surgical arthroscopy of hip with debridement/shaving of articular cartilage; resection of labrum of right hip
Codes:
M16.11, M11.251, M24.51, 29862-RT
ASA Crosswalk Lookup:
29862=4 base value units=01202
There is only one anesthesia code for the case
Overall anesthesia code for billing anesthesiologist
01202-QK-QS, P3
QS Monitored anesthesia care (MAC) is the anesthesia provided for this case. MAC involves the patient able to control his airway unlike general anesthesia but heavily sedated.
QK Medical direction of two, three, or four (CRNAs) concurrent anesthesia procedures involving qualified individuals. QK, like QY, AA, and AD are doctor’s codes from HCPCS II.
The physical status modifier is P3, a patient with severe systemic disease
Overall anesthesia code for CRNA service
01202-QX-QS, P3
QX CRNA service: with medical direction by a physician (can be for more than one CRNA). For CRNA’s billing code, only choose from QX or QZ.
Units calculation
Time units calculation is Time (in minutes)/15
Units=Base+time+PS+Emergency=
4+13.0+1+0=18.0
Case 4
Anesthesia time: 2:27 P.M. to 8:03 P.M.
Anesthesiologist, DD, MD directed the anesthesiology for the case
The neurosurgeon placed a radial arterial catheter, central venous internal jugular catheter, and Swan Ganz catheter
A cardiologist performed the transesophageal echocardiogram (TEE)
Anesthesia: General endotracheal
PS V
Patient is a 60 year old patient with uncontrolled hypertension who presents with hypertensive intracerebral hemorrhage and subdural hematoma as shown on CT scan
Diagnosis: Hypertensive nontraumatic acute subdural hemorrhage; intracranial intracerebral hemorrhage, intraventricular
Procedure: Burr hole with evacuation and drainage of subdural hematoma
Codes
I62.01, I61.5, I10, 61154-50
Although most acute subdural hemorrhages are the result of trauma, nontraumatic subdural hematomas can result in death. In this case, the patient had both hypertensive intracerebral hemorrhage and subdural hematoma. Neurosurgery was performed to evacuate and drain the subdural hematoma with a burr hole. This case falls into both pain management and anesthesiology
ASA Crosswalk Lookup
61154=9 base value units=00214
Overall anesthesiology code for the case
00214-AA-P5
The anesthesiologist personally provided the general anesthesia for the case.
The radial arterial catheter, central venous internal jugular catheter, and Swan Ganz catheter were placed by the neurosurgeon. For an anesthesiology case, these codes only count if the catheters are placed by the anesthesiologist or CRNA. Therefore, these are not coded. Likewise, the cardiologist performed the TEE. These were important for the case, but the TEE is not also coded for anesthesiology. The radial arterial catheter, central venous internal jugular, Swan Ganz catheter, and transesophageal echocardiogram are the only separately reportable procedure codes for anesthesiology if placed by the anesthesiologist or CRNA.
This patient is a moribund patient not expected to survive without the operation.
Therefore the Physical Status modifier is P5.
Units=Base+Time+PS+Emergency=
Time units=336/15=22.4
9+22.4+3+0=34.4 (round up or down)
Case 5
Anesthesia time: 06:00 A.M. to 8:17 A.M.
2 CRNAs, KR, BQ performed the anesthesia for the case without medical direction by an anesthesiologist
Anesthesia: General endotracheal
PS I
The anesthesia was complicated by utilization of total body hypothermia.
50 year old male with right shoulder pain. He lifts weights regularly. Limited ROM of right arm and pain on movement.
Diagnosis: Complete rotator cuff tear of right shoulder, not specified as traumatic
Procedure: Surgical arthroscopy of right shoulder, extensive debridement
Codes
M75.121, X50.0XXA, 29823-RT
ASA Crosswalk lookup
29823=5 base value units=01630
Overall anesthesiology code for the case for CRNAs
01630-QZ-P1
Anesthesia for open or surgical arthroscopic procedures on knee joint
QZ CRNAs performed the service without medical direction by a physician.
P1 The patient is a normal healthy patient.
Total units=Base+time+PS+Emergency=
5+9.13+0+5=19.1
The anesthesia was complicated by utilization of total body hypothermia. Therefore, 5 base value units are assigned from Emergency. The patient is a normal healthy patient; therefore the physical status modifier is P1.
Case 6
Anesthesia time: 04:44 P.M. to 05:29 P.M.
Anesthesiologist KS, MD performed anesthesiology for the case personally while medically directing five CRNAs
CRNAs JK, MF, LT, VB, SD
Anesthesia: General endotracheal
PS III
Diagnosis: Patient has a two year history of vesicoureteral-reflux. Patient has current urinary tract infection. A cystogram is performed, finding a stricture in the urethra
Procedure: Cystourethroscopy, with calibration and/or dilation of urethral stricture; Injection procedure for cystography
Codes
N13.70, N39.0, 52281, 51600-59
ASA Crosswalk Lookup
52281=3 base value units=00910
51600=3 base value units=00910
Overall anesthesiology code for the case
00910-AD-P3
00910 Anesthesia for transurethral procedures (including urethrocystoscopy)
In this case, there is a tie for anesthesia codes. However, the base value units are the same and the corresponding anesthesia code is the same for each CPT code for the case.
AD Medical supervision by a physician; more than four concurrent anesthesia procedures
P3 A patient with severe systemic disease; a two-year history of vesicoureteral-reflux and current urinary tract infection are severe systemic disease
Overall CRNAs code for the case
00910-QX-P3
QX CRNA service under medical direction by a physician, the anesthesiologist
Total units=Base+Time+PS+Emergency=
3+3.0+1+0=10.0
Cases for CANPC anesthesiology coding and pain management coding
Case 7
Anesthesia time: 11:00 A.M. to 1:03 P.M.
Anesthesiologist JR, MD personally provided the anesthesiology for the case
Anesthesia: General endotracheal
The anesthesia was complicated by emergency conditions.
PS III
The pt. is a 40 year old female patient with perforation of the intestine. She underwent exploratory laparotomy last week. The patient presented to the E.R. with extreme abdominal pain and tenderness and the patient made an unplanned return to the operating room during the post-operative period. The patient was found to have an emergency bleeding perforation of the intestine.
Diagnosis: Perforation of intestine; Other complication of surgical and medical care
Procedure: Re-opening of recent laparotomy
CPT codes
K63.1, T88.8XXA, 49002-78
Modifier 78=Unplanned return to the operating room during the post-operative period
ASA Crosswalk Lookup
49002=6 base value units=00840
Anesthesiology code
00840-AA-P3,
+99140
00840 Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; not otherwise specified
P3 The patient has severe systemic disease, perforation of the intestine
99140 Anesthesia complicated by emergency conditions (specify)(List separately in addition to code for primary anesthesia procedure)
Units calculation
Units=Base+Time+PS+Emergency=
6+8.2+1+2=17.2 (Can round up or down for CANPC exam)
Clinical viewpoint
The anesthesia was complicated by emergency conditions manifest by emergency bleeding.
Case 8
Anesthesia time: 06:00 A.M. to 11:56 A.M.
Anesthesiologist FR, MD provided the anesthesiology for the case
Anesthesiologist performed a transesophageal echocardiogram prior to the beginning of the operations.
Anesthesia: General endotracheal
PS I
The patient is a 35 year old male with severe lower back pains after an auto accident 2 months ago. He has a herniated spinal disk at L5-S1 and spondylolisthesis according to MRI.
Combined posterior interbody and lateral fusions with decompression, involving a complete laminectomy and bilateral foraminotomies, at L5-S1 is reported using the following codes to Medicare (note that other codes, such as those for instrumentation and bone grafts, may be separately reported):
Diagnoses: Intervertebral disc displacement; spondylolisthesis
Procedures: Complete laminectomy and bilateral foraminotomies L5-S1; Combined posterior interbody and lateral fusions with decompression
Codes
M51.26, M43.16, V89.2XXA, 22633, 63047-59
Clinical viewpoint
This case is both anesthesiology and pain management. In this case, the patient suffers from intervertebral disc displacement combined with spondylolisthesis, when one vertebra slips out of place to the vertebra below.
22633 Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; lumbar
63047 Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equine and/or nerve root(s), [eg. Spinal or lateral recess stenosis], single vertebral segment, lumbar
ASA Crosswalk Lookup
22633=8 base value units=00630
63047=8 base value units=00630
Overall anesthesiology code for the case
00630-AA-P1,
93312
00630 Anesthesia for procedures in the lumbar region, not otherwise specified
P1 Other than for the auto accident, the patient was a normal healthy patient with no systemic disease
Units calculation
Units=Base+Time+PS+Emergency=
8+23.7+0+0=31.7 (Can round up or down)
Clinical viewpoint
This patient suffered from an intervertebral disc displacement and spondylolisthesis which required two major pain management surgeries. Proper anesthesiology management and pain management was in addition critical to the case. The anesthesiologist performed a transesophageal echocardiogram at the beginning of the case. Therefore, TEE is coded separately. For TEE to be coded separately, the anesthesiologist must performed the procedure.
Case 9
Anesthesia time: 10:00 A.M. to 11:57 A.M.
JN, MD anesthesiologist performed the anesthesia for the case
JS, CRNA helped to perform the anesthesia under the direction of the anesthesiologist
JS, CRNA placed a radial arterial catheter at the beginning of the case
Anesthesia: General endotracheal
PS I
A 16-year-old boy is brought in because of a skateboarding accident. He sustained open wounds on both lower legs. The surgeon takes the patient to the OR for debridement. The wound on the left leg is 4 cm x 6 cm. The surgeon irrigates the wound and debrides the subcutaneous tissue and skin. When all of the debris is removed, he applies a dressing and then addresses the right leg. The wound on the right leg is 3 cm x 5 cm. This wound is deeper than the last, and requires debridement of nonviable muscle, subcutaneous tissue, and skin. What is the proper code selection?
Diagnoses: Open wounds on lower legs,; 4 cm X 6 cm left leg; and 3 cm X 5 cm right leg
Procedures: Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less; each additional 20 sq cm or part thereof (List separately in addition to code for primary procedure); Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less
Codes
S81.801A, S81.802A, V00.138A, 11042, 11045, 11043
ASA Crosswalk Lookup
11042=3 base value units=00400
11043=5 base value units=00300
11045=not a primary procedure code
Overall anesthesiology code for the case for the billing anesthesiologist
00300-QY-P1
Overall anesthesiology code for the case for the billing CRNA
00300-QX-P1,
36620
0300 Anesthesia for all procedures on the integumentary system, muscles and nerves of head, neck, and posterior trunk, not otherwise specified
P1 Other than the skateboarding accident, the patient is a normal healthy patient
Units calculation
Units=Base+Time+PS+Emergency=
5+7.8+0+0=12.8
Clinical viewpoint
The wound on the left leg required debridement of subcutaneous tissue and skin. Therefore, the correct CPT code was selected. The wound on the right leg was deeper and required debridement of nonviable muscle, subcutaneous tissue, and skin. When coding for debridement, concentrate on how deep the wound penetrates and the square cm.
Case 10
Anesthesia time: 4:09 P.M. to 4:46 P.M.
KL, MD Anesthesiologist performed the anesthesia for the case
Anesthesia: Monitored anesthesia care
PS II
A 60-year-old woman presents for follow-up with a pressure ulcer on her right heel. The wound measures 4 cm x 4 cm. She previously underwent extensive debridement. After review, the physician provides selective active wound care management. The wound was allowed to close by secondary intention. How is this coded?
Diagnosis: Pressure ulcer of right heel, stage 2
Procedure: Debridement (e.g. high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound (eg. fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq cm or less
Codes
L89.612, 97597
ASA Crosswalk Lookup
97597=5 base value units=00300
Overall anesthesiology code for the case
00300-AA-QS-P2
0300 Anesthesia for all procedures on the integumentary system, muscles and nerves of head, neck, and posterior trunk, not otherwise specified
P2 A patient with mild systemic disease; the patient only has one condition; pressure ulcer of heel
Units calculation=Base+Time+QS+Emergency=
5+2.3+0+0=7.3
If the patient were a Medicare patient,
Medicare units=Base+Time=
5+2.3=7.3
Clinical viewpoint
Selective active care wound management involves debridement of epidermis and dermis only, and therefore the code is 97597.
Case 11
Anesthesia time: 06:00 A.M. to 10:00 A.M.
PW, MD Anesthesiologist performed the anesthesiology for the case while directing five concurrent cases
Anesthesia: General endotracheal
Anesthesiologist placed radial arterial catheter and Swan Ganz catheter at beginning of case.
PS I
A 50 year old female presents with debilitating back pain with radiation to the right leg and numbness and tingling for two years. She was is otherwise healthy.
MRI scan shows thecal sac compression at L5-S1 facet joint and nerve root compression at L5-S1.
Diagnosis: Thecal sac compression L5-S1; nerve root compression L5-S1
Procedure: Laminectomy, facetectomy, and foraminotomy L5-S1 for thecal sac decompression and nerve root decompression above and beyond that necessary for the approach to the interspace to perform the interbody fusion; arthrodesis, posterior interbody technique, including laminectomy to prepare interspace (other than for decompression), single interspace; lumbar
Codes
G95.20, G54.8, 63047-RT, 22630-RT
ASA Crosswalk Lookup
63047=8 base value units=00630
22630=8 base value units=00630
In this case the split tie for the anesthesiology code made no difference. Both anesthesia codes are the same with equal base value units.
Overall anesthesiology code for the case
00630-AD-P1,
36620, 93503
00630 Anesthesia for procedures in lumbar region
AD Medical supervision by a physician; more than four concurrent anesthesia procedures
P1 Physical status modifier Normal healthy patient
Clinical viewpoint
This is a case outlining both anesthesiology and pain management. Laminectomy involves cutting out of the lamina, part of the neural arch of the vertebra extending from the pedicle to the median line. Facetectomy is cutting out of the facet, or articular part of the intervertebral joint. Foraminotomy means cutting into foramen, or a narrow passageway on both sides of the vertebra which allow nerve roots to travel from the spinal cord to other parts of the body. Arthrodesis is surgical fusion of a joint so that the bones grow solidly together. All four of these procedures are necessary to treat the compression of the thecal sac, which surrounds the spinal cord for sheathing and protection, and nerve root compression in this case.
The anesthesiologist performed anesthesiology on more than four concurrent anesthesia procedures and the type of anesthesia was general endotracheal, in which intubation is performed and the patient is not conscious and cannot maintain control over his own airway.
Case 12
Anesthesia time: 07:00 A.M. to 07:30 A.M.
FD, MD Anesthesiologist supervised 2 CRNAs for the anesthesiology of the case
DR, CRNA, WT, CRNA provided anesthesiology for the case under the medical direction of an anesthesiologist
Anesthesia: General endotracheal
PS I
A 17 year old high school football player accidentally burns his chest on a hot cautery instrument, resulting in a 4 cm X 4 cm burn with blisters. The burn is a second degree burn.
Diagnosis: Second degree burn on chest involving epidermis with penetration into dermis
Procedure: Active wound care management of second degree burn involving debridement of an open wound, epidermis and dermis, involving topical applications, wound assessment, and instructions for ongoing care
Codes
T21.21XA, T31.0, X16.XXXA, 97597
ASA Crosswalk Lookup
00300=5 base value units=97597
Overall anesthesiology code for the case for the billing anesthesiologist
00300-QK-P1
Overall anesthesiology code for the case for the billing CRNAs
00300-QX-P1
00300 Anesthesia for all procedures on the integumentary system, muscles and nerves of head, neck, and posterior trunk, not otherwise specified
QK Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals
QX CRNA service: with medical direction by a physician
P1 A normal healthy patient
Clinical viewpoint
The football player was burned by a hot instrument and a second degree burn developed on his chest. The burn involved the integumentary system. A second degree burn involves penetration into the epidermis and dermis. Active wound care management involves a debridement of the dermis and epidermis only, not the subcutaneous tissue. The burn was 16 sq cm. The anesthesia was for the debridement of the integumentary system, or the skin, hair, and nails. The integumentary system has a variety of functions; it may serve to waterproof, cushion, and protect the deeper tissues, which for this case is important for protecting the deeper tissues against the threat of a burn.
Case 13
Anesthesia time 08:00 A.M. to 10:49 A.M.
HF, MD Anesthesiologist performed the anesthesiology for the case while directing one CRNA
KF, CRNA was the CRNA for the case
KF, CRNA placed a central venous catheter in the subclavian vein
Anesthesia: General endotracheal
PS II
The anesthesiology for the case was complicated by controlled hypotension.
The pt. is a 35 year old female with mild gastroesophageal reflux disease. She swims a lot and suffered from cellulitis of both legs. She presents today one week later with extensive cellulitis.
The provider debrides 25 sq cm of subcutaneous tissue from the right leg, and 20 sq cm of subcutaneous tissue from the left leg.
Calculate units for both Blue Cross Blue Shield of CT and Medicare.
Diagnosis: Bilateral lower extremity cellulitis; gastroesophageal reflux disease
Procedures: Debridement of 25 sq cm of subcutaneous tissue from the right leg; Debridement of 20 sq cm of subcutaneous tissue from the left leg
Codes
L03.115, L03.116, K21.9, 11042 + 11045 X 2
ASA Crosswalk Lookup
11042=3 base value units=00400
Overall anesthesiology code for the billing anesthesiologist for the case
00400-QY-P2, +99135
Overall anesthesiology code for the CRNA for the case
0400-QX-P2, +99135
36556
0400 Anesthesia for procedures on the integumentary system on the extremities, anterior trunk, and perineum, not otherwise specified
+99135 Anesthesia complicated by utilization of controlled hypotension, corresponding to 5 base value units
Units calculation=Base+Time+PS+Emergency=
3+11.2+0+5=19.2 (Can round up or down)
Medicare units=Base+Time=
3+11.2=14.2 (Can round up or down)
Base units=Base=3
Time units=Anesthesia time/15=169/15=11.2
Clinical viewpoint
The code for the central venous catheter, 36556 can also be for the anesthesiologist since he supervised the CRNA for the case. Note that for the debridement, the sq cm counted for both the right leg and left leg combined; ie., the debridement codes are additive for the same code (subcutaneous, including dermis and epidermis (in this example). The patient suffered from controlled hypotension during the operation (see units calculation).
For anesthesia modifiers from HCPCS II:
Only two HCPCS II modifiers are correlated for the CRNA: QX, QZ.
For anesthesiologist, the HCPCS II modifiers AA, AD, QK, and QY correlate. These are the only codes for the anesthesiologist.
QS applies to a Monitored anesthesia care (MAC) service
Case 14
BN, MD anesthesiologist personally provided the anesthesia for the case
No CRNAs
The surgical resident placed the central venous catheter, internal jugular vein
PS III
A 15 year old boy has enlarged tonsils and adenoids. He is examined in detail by his primary care physician and found to have inflammation of the tonsils and adenoids for two years. He undergoes tonsillectomy and adenoidectomy.
Diagnosis: Chronic tonsillitis and adenoiditis
Procedure: Tonsillectomy and adenoidectomy
Codes
J35.03, 99214-25, 42821
ASA Crosswalk Lookup
42821=5 base value units=00170
Overall anesthesiology code for the billing anesthesiologist
00170-AA-P3
Clinical viewpoint
Anesthesia for intraoral procedures, including biopsy; not otherwise specified was provided by the anesthesiologist. The patient is over 12 years old (CPT code 42821). The central venous catheter is not coded for the anesthesiology coding since the surgical resident placed the line. The anesthesiologist, doctor providing the anesthesia, or CRNA must place the central line for the code to be coded for by the billing anesthesiologist. The anesthesiologist personally provided the anesthesia (HCPCS II modifier AA). The patient has severe systemic disease, i.e., chronic tonsillitis and adenoiditis (ICD-10-CM code J35.03).
Case 15
Anesthesia time: 06:40 A.M. to 11:17 A.M.
MM, MD Anesthesiologist performed the anesthesia for the case personally
The anesthesiologist placed a central venous catheter in the internal jugular vein for IV antibiotics
PS III
The pt. is a 55 year old female with sinus congestion for two years. He took a course of oral antibiotics for sinusitis two weeks recently. On exam the forehead is tender with maxilla. On CT scan and MRI there is inflammation of the frontal sinus and inflammation of the ethmoid sinus.
Diagnoses: Chronic frontal sinusitis; chronic ethmoidal sinusitis; chronic maxillary sinusitis
Procedures: Nasal sinus endoscopy, surgical with ethmoidectomy, total (anterior and posterior); Nasal sinus endoscopy, surgical, with maxillary antrostomy; Nasal sinus endoscopy, surgical with frontal sinus exploration with removal of tissue from frontal sinus
Codes
J32.1, J32.2, J32.0, 31255, 31256, 31276-59
ASA Crosswalk Lookup
31255=5 base value units=00160
31256=5 base value units=00160
31276=5 base value units=00160
Overall anesthesiology code for the billing anesthesiologist
00160-AA-P3,
36556
Units calculation
Units=Base+Time+PS+Emergency=
5+18.4+1+0=24.4 (Can round down or up for CANPC exam)
Clinical viewpoint
The patient has sinusitis on three sinuses as shown by CT and MRI, maxillary, frontal, and ethmoidal. The patient has severe systemic disease.and therefore a physical status modifier P3. Maxillary antrostomy or opening of an antrum, or cavity of a bone for draninage, total ethmoidectomy, and frontal sinus exploration with removal of inflamed tissue are performed as treatment of this severe condition. There is a three-way tie from ASA Crosswalk Lookup, but all CPT codes correlate with 00160 for the overall anesthesiology code. The anesthesiologist placed the central venous catheter in the internal jugular vein; therefore the central venous catheter is coded for in the anesthesiology case.
Cases for CANPC anesthesia and pain management coding
Case 16
Anesthesiologist personally provided the anesthesia for the case
Anesthesia: General endotracheal
PS III
The pt. is a 55 year old male with a 6-month history of abdominal pain, weight loss, and jaundice. His bilirubin level is elevated. The primary care physician refers the patient to a gastroenterologist, who performs endoscopic retrograde cholangiopancreatography to evaluate the patient for his symptoms and hyperbilirubinemia.
Diagnosis: Abdominal pain, weight loss, and hyperbilirubinemia
Procedure: Endoscopic retrograde cholangiopancreatography
Codes
R10.9, R63.4, E80.7, 43260
ASA Crosswalk Lookup
43260=5 base value units=00740
Overall anesthesiology code for billing anesthesiologist
00740-AA-P3
00740 Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum
Clinical viewpoint
This patient required ERCP to evaluate his abdominal pain, weight loss, and hyperbilirubinemia. The patient has severe systemic disease, correlating with physical status modifier P3. The endoscopic retrograde cholangiopancreatography is an upper gastrointestinal endoscopic procedure in which the endoscope is introduced proximal to the duodenum. The anesthesiologist personally provided the anesthesiology for the case (modifier AA).
Case 17
Anesthesiologist personally provided the anesthesiology for the case
Anesthesia: General endotracheal
PS I
Healthy 55 year old male with four children has a vasectomy and postoperative semen examination
Diagnosis: Encounter for sterilization
Procedure: Bilateral vasectomy including postoperative semen examination
Codes
Z30.2, 55250
ASA Crosswalk Lookup
55250=3 base value units=00921
Overall anesthesiology code for billing anesthesiologist
00921-AA-P1
00921 Anesthesia for procedures on male genitalia (including open urethral procedures); vasectomy, unilateral or bilateral
AA Anesthesiologist personally provided the anesthesiology for the case
P1 The patient is healthy
Case 18
Anesthesiologist personally performs the anesthesia for the case while running five concurrent procedures
Anesthesia: General endotracheal
PS I
A 25 year old healthy male injures his left knee.
Diagnosis: Torn medial meniscus, left knee
Procedures: Arthroscopy with major synovectomy, two or more compartments; Arthroscopy with medial meniscectomy including debridement/shaving of articular cartilage (chondroplasty)
Codes
S83.242A, 29876-LT, 29881-LT
ASA Crosswalk Lookup
29876=4 base value units=01400
29881=4 base value units=01400
Overall anesthesiology code for the billing anesthesiologist
01400-AD-P1
01400 Anesthesia for open or surgical arthroscopic procedures on knee joint; not otherwise specified
AD Medical supervision by a physician; more than four concurrent anesthesia procedures
P1 The patient is a normal healthy patient
Clinical viewpoint
The patient receives a synovectomy and medial meniscectomy for a torn medial meniscus of the left knee. The anesthesia is for open or surgical arthroscopic procedures on the knee joint. ASA Crosswalk Lookup shows a tie, but it makes no difference since the anesthesia code is the same.
Case 19
Anesthesiologist personally provided the anesthesiology for the case
Anesthesia: General endotracheal
PS I
The patient is 65 a year old female who presents with age-related nuclear cataract of the left eye. He undergoes cataract surgery.
Diagnosis: Age-related nuclear cataract, left eye
Procedure: Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique utilizing phacoemulsification
Codes
H25.12, 66984-LT
ASA Crosswalk Lookup
66984=4 base value=00142
Overall anesthesiology code for the billing anesthesiologist
00142-AA, P1
Clinical viewpoint
This patient has what is known as an age-related cataract of the nucleus of the lens of the eye. He undergoes cataract surgery utilizing phacoemulsification to remove the cataract and replace the cataract with in intraocular lens prosthesis. The anesthesia was performed for procedures on the eye; lens surgery. The anesthesiologist performed the anesthesiology for the case. The patient is a normal healthy patient.
 
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