Anesthesia Coding Alert

Question: A trauma patient with multiple facial injuries needed prolonged ventilation. The surgeon attempted a tracheostomy twice but aborted due to complications and airway difficulty. The patient was under anesthesia for 90 minutes, then transferred to the ICU (intensive care unit) with oral intubation. How would I code this case, considering the tracheostomy was unsuccessful and I'm unsure of the diagnosis?

Nebraska Subscriber

Answer: Begin with a diagnosis of V64.1 (Surgical or other procedure not carried out because of contraindication) and anesthesia code 00320 (Anesthesia for all procedures on the esophagus, thyroid, larynx, trachea and lymphatic system of neck; not otherwise specified, age 1 year or older). The circumstances should support reporting 99140 (Anesthesia complicated by emergency conditions [specify] [List separately in addition to code for primary anesthesia procedure]). You probably do not need to append any modifiers (such as -53 -- Discontinued procedure) because the anesthesiologist's service was complete. The exception is with carriers that may request modifier -53 when the surgery is not complete, so verify the carrier's guidelines.

Report whatever time the anesthesia provider spent continuously with the patient.