Anesthesia Coding Alert
Include Clear Documentation of Anesthesia During Extubation
Question: Is it possible to charge for an extubation procedure? The surgeon did the extubation, and we provided MAC for it. The procedure lasted nearly an hour and had a supporting diagnosis of mandibular abscess. Florida Subscriber Answer: Needing anesthesia during an extubation is extremely rare. As such, there is no CPT® code specifically for extubation, so you must choose the closest appropriate code and explain it to the carrier. Use 01999 (Unlisted anesthesia procedure) and include the procedure description as well as supporting documentation to explain the need for an anesthesiologist. Don’t forget to append a QS modifier (Monitored anesthesia care service) if the carrier requires it and to also include the supporting diagnosis. If you have a comorbidity that explains why anesthesia was medically necessary, report it as a primary code and M27.2 (Inflammatory conditions of jaws) as the secondary.
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