Anesthesia Coding Alert

Your anesthesia report may not tell the whole story

One trick to correct coding is to use the surgical report and any other documentation available instead of simply relying on the anesthesia record. "Some cases turn into big, involved procedures, and the only way you can be accurate is with the surgical record," says Vicki Embich of West Florida Medical Center Clinic in Pensacola. Embich and Kim Arnett, CPC, of Georgia Anesthesiologists in Marietta, share two examples that demonstrate how your coding can change depending on the information at your disposal.

Example 1:

Anesthesia Record Details: Exploratory laparoscopy and hip fracture treatment

Code Based on Anesthesia Record: 01210, Anesthesia for open procedures involving hip joint; not otherwise specified -- six base units

Surgical Report Details: Resection of liver, splenectomy and treatment of broken hip

Code Based on Surgical Report: 01230, Anesthesia for open procedures involving upper 2/3 of femur; not otherwise specified -- six base units (Although your base units don't change from how you would code based on the anesthesia record, reporting 01230 is more accurate.)

Example 2:

Anesthesia Record Details: Exploratory laparoscopy

Code Based on Anesthesia Record: 00790, Anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; not otherwise specified -- seven base units

Surgical Report Details: Hepatectomy

Code Based on Surgical Report: 00792, Anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; partial hepatectomy or management of liver hemorrhage (excluding biopsy) --13 base units.