Anesthesia Coding Alert

Question: Sometimes our anesthesiologist is asked to provide MAC (monitored anesthesia care) when the referring doctor can't sedate the patient. How do we handle the first instance?

Texas Subscriber

Answer: If you're coding for the first time the patient experiences a failure to be sedated, the most appropriate diagnosis is 995.24 (Failed moderate sedation during procedure). Verify that documentation includes details regarding the surgeon's and anesthesiologist's work and the patient's response.

Future care: If one of your anesthesiologists treats the patient again, the record should note the failed sedation. The situation would then be considered part of the patient's history, so include diagnosis V15.80 (Personal history of failed moderate sedation).