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new coder to anesthesia

  1. #1
    Unhappy new coder to anesthesia
    Medical Coding Books
    My past job I coded off operative reports for surgeons, I changed my career to anesthesia billing and am finding it very difficult to code off the anesthesia record with only a few words describing the surgery. They are very vague and I have a list of different CPT codes that I can use from their vague description. For example they asked me to code "cardiac catherazation", there are a number of different CPT codes to use how do you know which one, I am told whatever is the closest. I don't work that way, I am wondering if I had the operative report or the CPT code that the hospital used can I use that to code off of it? How accurate should we bill for Anesthesia, is it really so different than surgeon's billing? I can see if we were only putting in the ASA code in our system but charge entry needs the CPT code to cross over for the ASA code. The bills for some insurance companies go out with just the ASA code on them, while others go out with the CPT code and ASA code on them. Any advice or how I can approach them is greatly appreciated!

  2. #2
    We code from both the surgeon's notes and the anesthesia record which primarily gives us time but may include other important info about cath placement etc... There are instances when the CPT code crosswalks to more than one possible ASA code. I don't think you can code without the op notes from the surgeon.

    Holly M.

  3. #3
    I used to code for anesthesia, and it is hard to get used to not being so specific. If I really had a question, especially for cardiac cases, I would contact the surgeons office to see what CPT they used. Other than that it is based on time and if they did a couple of procedures, we would pick the one that had the highest base. If you need both the CPT and ASA, you definitely need more information if you can't read the anesthesia record; also use the crosswalk book, it really helps.

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