Anesthesia Coding Alert

Question: The patient had video-assisted thoracic surgery (VATS) and middle lobe lobectomy because of cancer in the right lung. As part of his documentation, the anesthesiologist circled, “GA and continuous thoracic epidural, DLT (double lumen tube), unusual position.” Why would the anesthesiologist use both general anesthesia and an epidural during the procedure?

Minnesota Subscriber

Answer: The anesthesiologist often will insert an epidural to help relieve postoperative pain when the patient undergoes a deeply invasive lung procedure (such as a wedge or lobe resection).

Your documentation will need to show that the anesthesiologist didn’t start with an epidural during the procedure and convert to general anesthesia. Notes will need to show that the epidural was separate from the general anesthesia and for a specific postoperative purpose. You should also have documentation of the surgeon asking for the postoperative pain relief.

Depending on the exact procedures performed, the surgical code might be either 32663 (Thoracoscopy, surgical; with lobectomy [single lobe]) or 32669 (Thoracoscopy, surgical; with removal of a single lung segment [segmentectomy]). Both procedures cross to anesthesia code 00541 (Anesthesia for thoracotomy procedures involving lungs, pleura, diaphragm, and mediastinum (including surgical thoracoscopy); utilizing 1 lung ventilation) as the primary choice and 00540 (Anesthesia for thoracotomy procedures involving lungs, pleura, diaphragm, and mediastinum [including surgical thoracoscopy]; not otherwise specified) as an alternate. Code 00541 carries 15 base units and code 00540 has a base unit value of 12.

DLT check: The notation about DLT (double lumen tube) is a clue that you should check whether the anesthesiologist used one lung ventilation during the surgery. One lung ventilation is a complication to surgery that allows the anesthesiologist to report three extra units. However, using a DLT doesn’t always indicate one lung ventilation. Look for the specific term “one lung ventilation” or notes such as “lung up” or “lung down” or corresponding direction arrows before making assumptions.

You’ll also need more details before coding the postoperative epidural. Report a continuous epidural to the thoracic area with 62318 (Injection[s], including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], not including neurolytic substances, includes contrast for localization when performed, epidural or subarachnoid; cervical or thoracic). Ensure that you meet the ASA’s recommendations for providing postoperative pain management services:

·         A request in writing from the surgeon for the anesthesiologist to provide post-op management

·         Anesthesia for the surgical procedure was not dependent upon the regional used for post-op management

·         Time spent on pre- or post-op placement of the thoracic epidural is not included in the reported anesthesia time for the surgery.

Each additional day of postoperative epidural management should be coded with 01996 (Daily hospital management of epidural or subarachnoid continuous drug administration).