Anesthesia Coding Alert

Question: Our anesthesiologist spent about 20 minutes on a Medicare patient’s pre-anesthesia exam, then the surgery was cancelled. How should we code to appropriately cover this scenario?

Iowa Subscriber

Answer: A choice from hospital care E/M codes 99231-99233 will cover this situation. Base your code selection on your provider’s pre-anesthesia documentation. Your choices are:

• 99231 – Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs …
• 99232 – Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs …
• 99233 – Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs … .