Anesthesia Coding Alert

Question:  Our anesthesiologist was present during a procedure that started as an open Nissen fundoplication. Major complications arose, and a cardiologist was called in. That made the cardiologist the primary surgeon and the original physician the assisting surgeon. 

One surgeon billed 43117 and 44005 with diagnoses 530.2 (Ulcer of esophagus), 530.10 (Esophagitis, unspecified), 568.0 (Peritoneal adhesions [postoperative] [postinfection]) and 560.9 (Unspecified intestinal obstruction). The second surgeon billed 43121 with diagnoses 862.22 (Other specified intrathoracic organs, without mention of open wound into cavity; esophagus) and 530.11 (Reflux esophagitis).

The anesthesia op report stated: General endotracheal with single lumen, converted to double lumen for the thoracotomy portion and intercostal nerve blocks with 0.50 percent marcaine with epinephrine. An A-line was placed. Start time was 12:40; end time was 19:30. PPO insurance is to be billed.

Do I include modifier -62 on the claim since two surgeons handled the case? Do I split the time from when one surgeon stopped and the other took over? Can the change to a double lumen and the nerve block be billed?

Vermont Subscriber

Answer:  Even though a hand-off took place between surgeons, you’re still only billing for one anesthesia procedure because there was one induction and one emergence. Therefore, you only bill one anesthetic.

When surgeons complete more than one procedure during an encounter, the anesthesiologist bills based on which procedure has the highest associated base units. Here’s the breakdown of the surgical codes and their associated anesthesia codes and units:

• 43117 (Partial esophagectomy, distal two-thirds, with thoracotomy and separate abdominal incision, with or without proximal gastrectomy; with thoracic esophagogastrostomy, with or without pyloroplasty [Ivor Lewis]) crosses to anesthesia code 00500 (Anesthesia for all procedures on esophagus), which has 15 base units.
• 44005 (Enterolysis [freeing of intestinal adhesion] [separate procedure]) crosses to 00790 (Anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; not otherwise specified), which carries 7 base units.
• 43121 (Partial esophagectomy, distal two-thirds, with thoracotomy only, with or without proximal gastrectomy, with thoracic esophagogastrostomy, with or without pyloroplasty) also crosses to 00500.

Because 43117 and 43121 both cross to a 15-base unit anesthesia code (00500), report 00500 for the anesthesia service. Securing an airway by placing a double lumen tube is included in the base units (global anesthesia fee). The time required to place this should be included in the time component of the anesthesia bill.

When you calculate your time units, you get 27 1/3 units. Add those to the 15 units of code 00500 for a total of 42 1/3 units for billing.

Placing an arterial line during surgery is one of the few services an anesthesiologist can bill in addition to anesthesia catheterization or cannulatio codes. Report the A-line placement with 36620 (Arterial n for sampling, monitoring or transfusion [separate procedure]; percutaneous). Remember this is a flat-fee surgical service so you don’t report time units associated with the placement.

Using modifier -62 (Two surgeons) is meant for surgeons, not anesthesia providers. Your claim for the anesthesiologist should only include 00500, 36620, and medical direction modifiers if required by the payer.