Anesthesia Coding Alert

Multiple services add base units to complex procedure

A reader recently posted the following case study on The Coding Institute's Anesthesia & Pain Management discussion group. Determine how you would code this procedure, then follow our experts' advice to determine all of the codes that your anesthesiologist can bill for this emergency case:

Case study: Our physician provided anesthesia during an exploratory laparotomy for a perforated bowel obstruction, and also documented a separate charge for arterial line (A-line) insertion. Later, he initiated positive pressure ventilation (first day). The patient is P3 (A patient with severe systemic disease), and the chart indicates that the case was an emergency because of septic shock. How should I code this?

First step: You should report either 44120 (Enterectomy, resection of small intestine; single resection and anastomosis) or anesthesia code 00790 (Anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; not otherwise specified) for the laparotomy, depending on whether the carrier requires surgical or anesthesia codes.

Next step: CPT's anesthesia guidelines state that traditional anesthesia service does not include unusual forms of monitoring (such as intra-arterial, central venous and Swan-Ganz catheters). You can therefore report 36620 (Arterial catheterization or cannulation for sampling, monitoring or transfusion [separate procedure; percutaneous]) for the A-line insertion and receive 3 more base units.

99140 Adds Two Additional Units

Bonus: Based on the patient's physical status (P3), you can also report emergency code +99140 (Anesthesia complicated by emergency conditions [specify]), which adds two units to your claim if your carrier reimburses for the "qualifying circumstances" codes (Medicare does not). CPT defines an emergency as when a treatment delay would lead to a significant increase in the threat to life or body part. Not all carriers reimburse for this add-on code, but you should still report it to code compliantly for statistical data collection and other uses of CPT/ICD-9 codes, says Marvel J. Hammer, RN, CPC, CHCO, owner of MJ Consulting in Denver.

Consider this: Coders' recommendations vary for reporting septic shock. Some experts recommend 569.83 (Perforation of intestine) as the primary diagnosis, with supporting diagnoses such as 560.2 (Intestinal obstruction without mention of hernia; volvulus), 518.5 (Pulmonary insufficiency following trauma and surgery) and 998.0 (Postoperative shock). (The additional diagnoses help justify postoperative ventilation.)

Code 995.92 (Systemic inflammatory response syndrome due to infectious process with organ dysfunction) is another possibility, Hammer says, depending on how much information you have. But you must first code the underlying condition and use an additional code to specify organ dysfunction (such as 785.52, Septic shock) before reporting 995.92.

Don't forget: After you code the procedure itself, you should review the follow-up service of initiating positive pressure ventilation. Before coding this ventilation management, first verify when "later" was -- did the physician initiate vent management during the procedure's anesthesia time, then put on a vent prior to the end of anesthesia time once the patient transferred to the intensive care unit (ICU)? If so, the vent management is part of anesthesia and is not separately billable.

Tip: You can report vent management separately if the anesthesiologist initiated it after the procedure's anesthesia time ended. The primary code is 94656 (Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; first day), but remember, this code includes the ventilation management for the entire first day. Verify that the anesthesiologist performed and documented this management, Hammer says. If he simply gave the first settings after the patient transferred to ICU, you should not report 94656.

Planning: Report additional vent management days with 94657 (Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; subsequent days). This code describes a medical procedure rather than an anesthesia service, so you should report 94657 as type of service (TOS) 01 (Medical service).

Your choice: Some coders prefer to report critical care codes instead of ventilator management codes in these cases: