Anesthesia Coding Alert

Knowing small details can make a big difference in your claims.

Because CPT^® anesthesia codes are based on anatomic location, verifying the procedure location and surgical approach can be the difference in choosing between options such as 00600 (Anesthesia for procedures on cervical spine and cord; not otherwise specified) with 10 base units or 00604 (…procedures with patient in the sitting position) with 13 base units.

Ask yourself these types of questions to ensure you choose the best coding option for any situation:

·         What body area is involved? Extemity (upper or lower)? Skin (where on the body)? Abdomen (upper or lower)? Getting operative notes or other documentation can usually give you all the details needed to determine the correct anatomic location.

·         What surgical approach was used? Laparoscopic, thorascopic, or endoscopic? Laparotomy, thoracotomy, or another incision?

·         What was the patient’s position? Prone, supine, beach chair, or other?

Being familiar with common medical terms can also offer more coding clues. For example:

·         “Distal incision” describes an incision that is away from the body’s center (such as from the wrist to the finger tip).

·         “Upon entrance the liver was viewed.” Because of the liver’s location, this type of phrase could identify a procedure in either the upper abdomen or lower thoracic cavity. Query the surgeon for more details.

·         “An incision was made lateral to the umbilicus and taken in a cephalic direction.” This note means the incision was made on the side and in an upward direction.

Top tip: “It’s important that coders understand they should code where the procedure is performed, not just where the incision is made,” says Kelly Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Fl. Keeping that in mind will always help point you in the right anatomic direction.