Anesthesia Coding Alert

Don’t be afraid to dig through the surgeon’s documentation for key details.

When coding for anesthesia during coronary artery bypass graft (CABG) procedures, factors such as the patient’s age and whether physicians used specialized equipment during the operation can affect your reporting. With so many considerations, trying to figure out proper coding for these surgeries can get a bit tricky.

If you need a refresher on how to navigate these nuances to ensure appropriate reimbursement, read on. Check out these four simple steps that, if followed, will set you on a path toward CABG claim success.

Step 1: Know All the CABG Code Choices

CPT^® includes three codes for anesthesia during CABG procedures on patients with an atherosclerotic condition:

• 00562 (Anesthesia for procedures on heart, pericardial sac, and great vessels of chest; with pump oxygenator, age 1 year or older, for all noncoronary bypass procedures … or for re-operation for coronary bypass more than 1 month after original operation)
• 00566 (Anesthesia for direct coronary artery bypass grafting; without pump oxygenator)
• 00567 (Anesthesia for direct coronary artery bypass grafting; with pump oxygenator)

The associated base units vary according to the procedure. Code 00562 carries 20 base units, code 00566 carries 25 base units, and code 00567 carries 18 base units. It’s important to note that the ASA CABG codes have already been valued to factor in hypothermia (body core temperature below 95.0°F) and cardioplegia (the deliberate temporary stopping of the heart via pharmacological therapy, typically to permit heart surgery).

“The codes to report grafting of coronary arteries for non-atherosclerotic (i.e., congenital conditions) are 33503 (Repair of anomalous coronary artery from pulmonary artery origin; by graft, without cardiopulmonary bypass) and 33504 (… with cardiopulmonary bypass), and these route to 00561 (Anesthesia for procedures on heart, pericardial sac, and great vessels of chest; with pump oxygenator, younger than 1 year of age) through 00566,” says Doris V. Branker, CHC, CPC, CIRCC, CPMA, CPC-I, CANPC, CEMC, president at DB Healthcare Consulting, LLC in Sunrise, Florida.

Step 2: Check for Use of CBP

The first question you need to answer when coding anesthesia during CABG is whether a pump oxygenator was used during the procedure.

Definition: A pump oxygenator, also known as a heart-lung machine or cardiopulmonary bypass (CPB) machine, is a piece of equipment that temporarily takes over the work of both the heart (pump blood) and the lungs (oxygenate the blood).

When the pump is used (on-pump case), it keeps the patient’s blood oxygenated and flowing to the brain and other organs while the heart is stopped during surgery. “In CPB, the heart rate is dropped very low but not necessarily to zero. The heart rate is too low to sustain life but may not be completely arrested,” Branker notes.

When the pump isn’t used (off-pump case), the surgeon is operating on a still-beating heart. The physician must document “off pump” before you can report the codes with higher base unit values. “It can be worth approximately $140 more for an average Medicare case,” says Kelly D. Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I, president of Perfect Office Solutions in Leesburg, Florida. But be sure your anesthesiologist has earned it before you code it, and remember, the key to reimbursement is documentation.

Do this: Make sure to double-check that there’s supporting documentation before coding a case as off-pump. “Clues in the record would include a heart rate very close to zero, the abbreviation ‘CPB,’ or notations of ‘bypass on.’ It is additionally important to note that when bypass is done, it isn’t employed for the entire case due to its physiological effect on blood and its products,” Branker adds.

Step 3: Recognize When You Can Add Qualifying Circumstances

Some payers allow coders to report “qualifying circumstances” codes that explain aspects of the patient’s situation that complicated the anesthesiologist’s work. Add-on codes that might apply to cardiovascular cases include:

• +99100 (Anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure))
• +99116 (Anesthesia complicated by utilization of total body hypothermia …)
• +99135 (Anesthesia complicated by utilization of controlled hypotension …)
• +99140 (Anesthesia complicated by emergency conditions (specify) …)

Don’t automatically include these codes with all CABG procedures. Hypothermia and hypotension are often included in the anesthesia code and should not be reported separately in those cases.

Why? The cardiac bypass pump itself lowers the patient’s blood pressure and temperature without the anesthesiologist intervening. You cannot bill it separately because the service is part of the routine anesthesia care as indicated in the coding comments.

Example 1: Codes 00561 through 00563 (Anesthesia for procedures on heart, pericardial sac, and great vessels of chest; with pump oxygenator with hypothermic circulatory arrest) and 00567 include the total body hypothermia and controlled hypotension services represented by +99116 and +99135. Although CPT^® doesn’t include this information, the ASA Relative Value Guide includes parenthetical comments that the descriptors take hypotension and hypothermia into consideration.

Example 2: Code 00562, however, specifies that the patient is “age 1 year or older.” If the patient is under 1 year of age and you code a cardiovascular procedure with 00562, you can include +99100 because of the patient’s extreme age. Make sure the patient’s date of birth is documented to support this. Payers that recognize qualifying circumstances codes will typically pay one additional base unit for +99100.