Anesthesia Coding Alert

Question: I have to code the anesthesia portion of a complicated surgery. The patient originally went in for an open Nissen fundoplication, which the surgeon billed as 43117 and 44005. The related diagnoses were 530.2 (ulcer of esophagus), 530.10 (esophagitis, unspecified), 568.0 (peritoneal adhesions [postoperative] [postinfection]) and 560.9 (unspecified intestinal obstruction). An A-line was placed.

There were major complications during surgery. A cardiologist was called in, making the first surgeon the assisting surgeon. The second surgeon coded 43121, and diagnosis codes 862.22 (other specified intrathoracic organs, without mention of open wound into cavity; esophagus) and 530.11 (reflux esophagitis).

The anesthesia op report contained the following information: General endotracheal with single lumen, converted to double lumen for the thoracotomy portion and intercostal nerve blocks with 0.50 percent marcaine with epinephrine. Start time was 12:40; end time was 19:30. PPO insurance is to be billed.

Do I bill with modifier -62 (two surgeons)? Do I split the time from when one surgeon stopped and the other took over? Can the change to a double lumen and the nerve block be billed?

Washington Subscriber

Answer: This case was not two anesthesia cases there was one induction and one emergence. Therefore, only one anesthetic should be billed. In looking over the CPT codes you mentioned in your question, 43117 (partial esophagectomy, distal two-thirds, with thoractomy and separate abdominal incision, with or without proximal gastrectomy; with thoracic esophagogastrostomy, with or without pyloroplasty [Ivor Lewis]), 44005 (enterolysis [freeing of intestinal adhesion] [separate procedure]), 43640 (vagotomy including pyloroplasty, with or without gastrostomy; truncal or selective) and 43121 (partial esophagectomy, distal two-thirds, with thoracotomy only, with or without proximal gastrectomy, with thoracic esophagogastrostomy, with or without pyloroplasty), 43121 and 43117 have the most base units. Both of these CPT codes crosswalk to 00500 (anesthesia for all procedures on esophagus), which is 15 units plus time. Both of those codes address the thoracotomy for esophageal surgery. Securing an airway by placing a double lumen tube is included in the base units (global anesthesia fee). The time required to place this should be included in the time component of the anesthesia bill.

The procedure should be billed simply as one anesthetic with multiple procedures: Code 00500 is 15 units + time = 42 1/3 units for billing.

Most carriers will reject nerve blocks placed by anesthesia in the operating room (remember the anesthesiologist is already billing for this time). A-lines, Swan and CVPs are not bundled to the anesthesia fee. If the A-line was placed by the anesthesiologist, that can be billed separately using 36620. Using modifier -62 is appropriate for the surgical service, but we do not use it when billing for anesthesia services.

In summary, when multiple procedures are done in the operating room, bill the one with the highest start-up value and add time units. In this case, it is clearly best to bill with 43117 or 00500, depending on which the carrier prefers.