Anesthesia Coding Alert

Hint: Don't assume it's the point of incision.

Anytime you code for anesthesia during an abdominal procedure, you must determine whether the surgeon worked in the upper or lower abdomen. Read on for our experts' advice on how to know which area you should report.

Background: Every anesthesia code is associated with multiple surgical procedures that can be performed in that anatomic area. CPT® includes 14 codes for upper abdominal anesthesia and 25 codes for lower abdominal anesthesia. Two prime examples that can confuse coders are:

• 00790 -- Anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; not otherwise specified
• 00840 -- Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; not otherwise specified.

Study Opinions on 'Dividing Line'

"Knowing the 'dividing line' between upper and lower is an ongoing topic of discussion in our office," says Pam Stopher, CPC, ACS-AN, with Park Medical Management, Inc., in Memphis, Tenn.

"I always wondered how to handle these situations, until we asked an auditor who did an internal audit of our work," adds Shelley Hamm, RHIT, coding specialist with Professional Solutions Stat in Saint Louis, Mo.

Common opinions can include:

• Where the physician spends the most time during surgery
• The surgical location in relation to the umbilicus (anything above the umbilicus is upper abdomen, anything below is the lower abdomen)
• The point of incision (above or below the umbilicus).

Caution: Although the point of incision can point you toward the correct upper/lower answer, that isn't always the case. Instead, focus on where the procedure is performed more than the incision point.

Bonus tip: Some procedures cross to both upper and lower abdominal anesthesia codes, which alerts you to pay close attention to the site of treatment. For example, code 49324 (Laparoscopy, surgical; with insertion of tunneled intraperitoneal catheter) crosses to both 00790 and 00840, depending on whether the procedure is classified as upper or lower abdominal. Coding guidelines direct you to report 00790 if the physician places the catheter above the umbilicus.

Focus on Terminology, Exploration

Your provider's documentation is the key to determining upper versus lower abdomen. If the anesthesia record doesn't specify the location, check the OR record. The surgeon will definitely know the area he treated, whereas the anesthesiologist might not know the specifics.

"Getting our providers to document correctly is the biggest challenge," Stopher says. "The best thing I've found that works is taking the paperwork back to the physician or CRNA." If the documentation needs to be updated, the provider can add a note to the record and initial it as an addition or update.

Watch for wording that can indicate an upper or lower abdominal procedure. Terms the surgeon might use could include:

• "Upper midline," "subcostal," "supraumbilical," "paramedian," "colon," or "small bowel" for upper abdomen
• "Infraumbilical," "lower midline," "elliptical," "Pfannenstiel," or "Rutherford-Morrison" for lower abdominal approaches.

Also distinguish between exploration and the actual procedure. "The pelvic area might be explored because of trauma, along with a small bowel resection," Hamm says. "In that case you'll code the procedure as upper abdomen because the lower area was only explored and more than half the surgery was focused on resecting the small bowel."

Tip: When you're coding for procedures in the small intestine, the American Society of Anesthesiologists considers "upper abdomen" to be anything from the colon through the sigmoid colon. Procedures focusing specifically on the sigmoid or rectum are considered "lower abdomen."

Upper and Lower Leads to Single Code

In some cases, the procedure involves both the upper and lower abdominal area. You only report a single code for the anesthesia rather than codes for both areas.

Here's how: Look at the correct anesthesia codes for each part of the procedure and report the one with the higher base unit. For example, code 00790 has a base unit value of 7, and code 00840 has a base unit value of 6. You would report 00790 and link it to the total time of the procedure (including both the upper and lower abdominal work).