Anesthesia Coding Alert

Question: An anesthesiologist at our facility spent about 20 minutes on the pre-anesthesia exam, then the surgery was cancelled.  The payer is Medicare. How should we code to appropriately cover this scenario?

Texas Subscriber

Answer: A choice from hospital care E/M codes 99231-99233 will appropriately cover this situation. The code selection will be based on the pre-anesthesia documentation. The descriptor codes are as follows:

• 99231: (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: problem focused interval history; problem focused examination; Medical decision making that is straightforward or of low complexity). 
• 99232: (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history;An expanded problem focused examination;Medical decision making of moderate complexity). 
• 99233: (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A  detailed examination; Medical decision making of high complexity).