Anesthesia Coding Alert

Question: Upon emergence, a hernia repair patient experienced cardiac arrest, so staff began CPR and cardioversion. They moved the patient to the cardiac catheterization lab and conducted coronary angioplasty with MAC (monitored anesthesia care). Our anesthesiologist was with the patient the entire time. She listed the times 0938 to 1125 and 1126 to 1435 on the record. How should I code this case?

California Subscriber

Answer: Having documentation of two start and stop times suggests that the anesthesiologist extubated the patient. Your coding will depend partly on whether that is true, so verify that detail with your anesthesiologist.

If she did extubate the patient, report 00830 (Anesthesia for hernia repairs in lower abdomen; not otherwise specified) with an end time of 1125. Report the angioplasty with 01925 (Anesthesia for therapeutic interventional radiological procedures involving the arterial system; carotid or coronary) and a start time of 1126. Remember to report the appropriate cardiac-related diagnosis for the second procedure, such as I46.x (Cardiac arrest). You may also want to report a 59 modifier (Distinct procedural service) on the second service to separately identify the two anesthesia sessions.

No extubation:  If the physician did not extubate the patient, however, you’re reporting a continuation of anesthesia. Report 01925 because it represents the higher-base-unit procedure, and include the full amount of continuous documented time. Make certain the documentation supports all events that occurred during this anesthetic session in the event the insurance company requests information regarding the extended length of anesthesia time reported.