Anesthesia Coding Alert

Hint: Details dictate how you report cases Many factors determine how you code anesthesia's involvement in canceled cases. Learning how far in advance the case was canceled, whether the anesthesiologist had induced the patient, and whether the surgeon had begun the case will help guide your coding. But individual circumstances and carrier guidelines also come into play, so you don't always have a set answer.
 
To test yourself, check out two examples of canceled cases, then read your coding options.
 
Example 1: The anesthesiologist performs a standard pre-op workup, but the procedure is canceled and rescheduled. What are your coding options for this workup and the second set of pre-op work when the case actually takes place? Assume the rescheduled date is several weeks from the cancellation, so it is far enough away to merit another complete preoperative consultation.
 
Correct Coding. You have two options for this case:

  Report the initial pre-op exam with the appropriate E/M code. When the surgery takes place later, only report the anesthesia code based on the procedure. The anesthesiologist will complete another round of pre-op work before the surgery, but the anesthesia code includes that fee, so you won't code it separately.

  Report the initial pre-op exam with the applicable anesthesia code (based on the planned surgery) and modifier -53 (Discontinued procedure). Again, the second set of pre-op work is part of the anesthesia fee, so you don't code it separately.

Example 2: A 40-year-old female patient is scheduled for myomectomy, excision of fibroid tumor of uterus. The patient becomes hypotensive after anesthesia induction and after the surgeon makes an incision. The surgeon closes the wound and discontinues the surgery.

Correct Coding. Submit the following codes:

  ICD-9's 218.x (Uterine leiomyoma), 458.29 (Other iatrogenic hypotension) and V64.1 (Surgical or other procedure not carried out because of contraindication).

  Procedure code CPT 00840 (Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; not otherwise specified) with modifier -53 (Discontinued procedure).