Anesthesia Coding Alert

Question: Our physician provided anesthesia for a bilateral periprosthetic capsulectomy of the breast. The surgeon also performed posterior colporrhaphy with repair of cystocele during the same session. How should I code the procedure?

Minnesota Subscriber

Answer: Report the procedure with the higher base value: in this case, 19371 (Periprosthetic capsulectomy, breast). The surgeon performed it bilaterally, but do not append modifier -50 (Bilateral procedure) because you are only reporting anesthesia services. (Modifier -50 is a surgical/procedural modifier. Anesthesia providers only report it for procedures such as bilateral injections for pain management.) Though you only code one procedure, bill the total time for anesthesia during both procedures.