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CANPC Anesthesiology coding essentials book 62 p. (1-19)

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    Default CANPC Anesthesiology coding essentials book 62 p. (1-19)
    Medical Coding Books
    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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