Anesthesia Coding Alert

Question: What should we document on the anesthesia record for a case involving controlled hypotension?

Virginia Subscriber

Answer: First, keep in mind that the anesthesia provider’s documentation must support an induced hypotensive state. The circumstances qualifying for this are unique to anesthesia coding and identify certain patient conditions, operative conditions, or other special risk factors that lead your provider to believe the patient needs to be in a hypotensive state during surgery.

The following phrases should be present in the record to support the use of 99135 (Anesthesia complicated by utilization of controlled hypotension [List separately in addition to code for primary anesthesia procedure]):

• Hypotensive state induced
• Surgeon’s request for hypotension initiated
• Blood pressure reduced to 80/50 per surgeon request

Key note: Do not rely on the patient’s charted blood pressure alone when assigning 99135. Code 99135 is intended to be used only when hypotension is induced deliberately, not when it occurs as an incidental condition.

Remember that 99135 is an add-on code, which means you must report it in conjunction with a primary procedure code. Acceptable primary codes that can be billed with 99135 (or any other add-on code) are at the payer’s discretion.

Extra tip: Make sure you don’t report 99135 separately when the anesthesia code you’re reporting already includes the service of 99135 (such as 00561, Anesthesia for procedures on heart, pericardial sac, and great vessels of chest; with pump oxygenator, younger than 1 year of age).