Anesthesia Coding Alert

Question: Our anesthesiologist was called into an in-office case to provide sedation for a GYN patient during her hysteroscopy/ablation. The patient wanted to try getting through the procedure without any sedation/anesthesia, so the anesthesiologist performed the pre-procedure exam, history, etc., and inserted the IV. He placed her on monitors and he gave her ketorolac and ondansetron. He did not administer sedation/anesthesia, but he was there the whole time to provide it, if needed. How do I accurately code the services the anesthesiologist provided?

Nevada Subscriber

Answer: There are two different ways to look at this question.

1) If there is not an anesthesia record, the anesthesiologist provided a standby service for the patient. CPT® includes a code for this: 99360 (Standby service, requiring prolonged attendance, each 30 minutes (eg, operative standby, standby for frozen section, for cesarean/high risk delivery, for monitoring EEG)). Insurers might not reimburse for the code, but you should still file the claim to document your provider’s presence. You code one unit of 99360 for every full 30 minutes of time the provider is on standby. For example, if he was there for 45 minutes you bill for 1 unit, but if he was there for 90 minutes you would bill 3 units.

2) Report CPT® 00952 (Anesthesia for hysteroscopy and/orhysterosalpingography). If the anesthesiologist provided all care normally associated with anesthesia, including the pre- and post-procedure exam/assessment, and fully documented everything in the anesthesia record, the service would be considered monitored anesthesia care (MAC). MAC does not require administration of an anesthetic agent to qualify for payment. The American Society of Anesthesiologists (ASA) provides a “Position on Monitored Anesthesia Care” in their practice guidance documents that you might find helpful. Make sure you remember to use the correct place of service code on your claim.