Anesthesia Coding Alert

Tip: Digging deeper into descriptors will stop your coding errors cold.

Qualifying circumstances codes can help boost your bottom line, but only if you report them correctly. Read on to learn how paying attention to three areas can keep you on the right coding track for hypothermia claims.

1. Verify Your Provider Induces Hypothemia

CPT® includes one add-on code for anesthesia affected by hypothermia: +99116 (Anesthesia complicated by utilization of total body hypothermia [List separately in addition to code for primary anesthesia procedure]).

• Dissecting the code descriptor tells you two important things about correctly reporting +99116:
• The term “utilization” lets you know that the patient’s hypothermic state was induced (that is, on purpose) and not incidental.

Because it’s an add-on code (designated by the “+” sign), you know you can report it only in conjunction with a comprehensive anesthesia code. That doesn’t mean it applies each time a chart mentions hypothermia, however.

2. Check That Hypothermia Is Not Inherent

A few anesthesia codes already include hypothermia, which means it’s invalid to append +99116 to the claim. The distinction is easier to note with some procedures than with others.

Example 1: Hypothermia inclusion is obvious with some codes, such as 00561 (Anesthesia for procedures on heart, pericardial sac, and great vessels of chest; with pump oxygenator, younger than 1 year of age). The code’s descriptor doesn’t spell it out, but the associated note does: “Do not report 00561 in conjunction with 99100, 99116, and 99135.”

“Coders must remember that for most heart cases, hypothermia is already included in the base of the anesthesia code,” explains Judy A. Wilson, CPC, CPC-H, CPCO, CPPM, CPC-P, CPB, CPC-I, CANPC, CMRS, business administrator for Anesthesia Specialists, PTR, in Virginia Beach.

Example 2: Other anesthesia codes also include hypothermia, though it’s less clear. Check out these examples:

• You can’t report +99116 with 00562 (... with pump oxygenator, age 1 year or older, for all non-coronary bypass procedures [e.g., valve procedures] or for reoperation for coronary bypass more than 1 month after original operation); the key terminology is “with pump oxygenator.” Look at the service this represents. Explanation: When your anesthesiologist uses a pump oxygenator during cardiac surgery, no blood circulates through the coronary arteries. Therefore, the myocardium (or heart muscle) is ischemic (meaning there is restricted blood supply). Hypothermia is a routine part of the procedure to help protect the heart from ischemic injury.
• Also, steer clear of reporting +99116 with 00563 (... with pump oxygenator with hypothermic circulatory arrest). The mention of a pump oxygenator sends you away from +99116, as does the hypothermic circulatory arrest. Your anesthesiologist induces hypothermic circulatory arrest to significantly slow cellular activity levels and stop blood circulation. Bringing the patient to that state allows the surgeon to safely complete procedures when he can’t use clamps to contain the blood flow. “This would take place during an aortic arch case as you cannot clamp off because the patient would surely have a stroke, for example,” Wilson says. “The temperature must be brought down to about 18 degrees Centigrade and the patient is in hypothermic circulatory arrest.”

Common, not a given: Your anesthesiologist will often induce hypothermia during intracranial surgeries to treat aneurysms, cerebral AV malformations, and other cerebrovascular procedures, but it’s not considered routine. In these cases, you can safely report +99116 in addition to the anesthesia code and garner your physician a well-deserved boost in pay.

3. Encourage Clear Documentation

As with any claim, you can code based only on your physician’s documentation. Simply charting the patient’s temperatures or noting “warming” in his notes won’t justify the use of +99116.

Instead, teach your anesthesiologist to include phrases such as “hypothermic state induced,” “surgeon’s request for hypothermia initiated,” or “temp reduced to 34.5 degrees C per surgeon request.” Then you’ll have what you need to legitimately add +99116 to your claim when the corresponding anesthesia code allows.