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Thread: Exam under anesthesia -- can't find a code

  1. #1

    Default Exam under anesthesia -- can't find a code

    AAPC: Back to School
    I need help with this one. I think we will just have to charge for a hospital visit....

    Examination under anesthesia for impalpable difficult to assess left testes in a child with cerebral palsy.

    Male with mild cerebral palsy who has spasticity who prior as a 2 yr old had bilateral retractile testes. have been following annually for some time. this year, we had difficulty assising his left testes in the office and it was electred at this time to schedule him for exam under anesthesia to be assured that the head presence of a left testes that indeed still remained retractile. both testes were difficult talways to deliver dure to their size as he has evidence of hypogonadism.

    in the supine postion under general inhalational anesthesia, prior to prepping the patient we assessed his inguinal scrotal regoin bilaterally. in the supine position, he was relaxed and his airway managed by anesthesia and a bit of sedation was given, we were able to identify both testes within the inguinal canals and they were retrievable and would deliver to their dependent scrotal compartments. both the left and right testes were retractile and very small, almost infantile . our final assessment was bilateral retractile testes. at this point, anesthesia was instructed to recover the patient and we proceeded to take the patient to PACU.

    Any help will be greatly appreciated.

  2. #2
    Join Date
    Apr 2007
    Lexington Kentucky Chapter


    So I'm guessing you have already looked at 54550 - 54560?

  3. #3
    Join Date
    Apr 2007
    Las Vegas, Nevada


    I would use the unlisted code 55899 and send copy of operative report. If you are the anesthesia provider, crosswalk to 00920. Use ICD-9 codes to indicate the cerebral palsy and spasticity (343.9) to justify the general anesthesia.

  4. #4


    I did look at 54550 but can this be used since there was no incision made? just an exam was done,

  5. #5
    Join Date
    Apr 2007
    Milwaukee WI

    Default Unlisted

    I agree with bwolfe ... unlisted code and submit op notes with documentation of need for exam under anesthesia.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  6. Cool Marshall test

    What code is used for a Marshall Test for urinary incontinence

  7. Default

    EUA- or Exam under anesthesia code(s). I can appreciate your frustration with trying to find this code. Yes, there was once a code for EUA procedures. However, please go to the 99143 section of your CPT coding book. Now and even more so is the Moderate Sedation codes being used. The codes vary by age group. I believe you can use this since your anesthesia was supported or maintained by the use of an adjunct to keep the pt. comfortable. Unfortunately, you didn't mention which agent you used. If you are a physician, then the 99148 code should be alright. < 5yrs. of age since it appears as if you were monitoring this pt. separately during this procedure. The other code is for physician or CRNA giving the sedation while performing the procedure at the same time.

    I hope this helps your coding situation. The previous general anesth. code for EUA was deleted a while back, but it did exist.
    Helen Strasko, RN, CPC, CCRN, CLNC

  8. Default

    Marshall test or Marshall-Machetti test for urinary incontinence is merely asking the patient to cough. If while coughing the patient leaks urine from themselves, then it denotes a weak bladder (muscle) problem. It's also known as an A/P muscle problem and a gynecologist typically along with urologists perform a A/P repair for this to the muscles involved. (Anterior/Posterior). aka. Marshall-Machetti-Krantz, Burch, simple repair.
    (51840) for the operation to repair these muscles. The actual test is asking the patient to perform a cough. You might want to double check with the Office Mgr. on this one or write a narrative note in your billing section.
    Best wishes,
    Helen Strasko, RN, CPC, CLNC

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