Anesthesia Coding Alert

Question: Our physician tended a patient under anesthesia for about two hours for a craniotomy. The surgeon canceled the procedure after one hour due to equipment malfunction, and the patient went to NICU. The surgery resumed about three hours later. How should I code this procedure?

New York Subscriber

Answer: Although the first attempt at surgery was not fully completed, you can bill for the anesthesia. Some carriers request that you append modifier -53 (Discontinued procedure), but you have to check your individual carrier's guidelines before going this route.

Some coders recommend charging the procedure's base value for one session instead of for both sessions.
This is for several reasons: The interruption was equipment-related, the surgery resumed within hours, and the anesthesiologist did not need to repeat his pre-op work. Based on that line of thinking, this is a great example of discontinuous time - report one procedure code and add the anesthesiologist's time for each segment. Include any modifiers and related diagnosis codes that can help explain the situation. You should probably submit a paper claim so you can include copies of the anesthesia and operative reports for the carrier.

Caution: Don't overlook one final consideration in deciding whether the case qualifies for discontinuous time. Did the physician extubate the patient between procedures or leave him intubated? If he extubated the patient, you could possibly bill it as two separate cases instead of as one case with discontinuous time.