Anesthesia Coding Alert

Question: We’re having some confusion in our office about CPT^® codes such as 23655 with descriptors that state “with anesthesia.” I think this means general anesthesia instead of moderate sedation, but a new coder to our practice disagrees. Does CMS have any written guidelines about this?

Illinois Subscriber

Answer: An article from a CPT^® Assistant Special Edition in 2006 addressed this topic. It states, “Code descriptors that include the phrases ‘with anesthesia’ or ‘requiring anesthesia’ indicate that the work involved in performing that procedure requires anesthesia, whether it is general anesthesia, regional anesthesia, or monitored anesthesia care (MAC).”

Based on this information, the term “with anesthesia” includes both general anesthesia and moderate sedation. Procedures that involve conscious sedation do not fall under this definition.