Anesthesia Coding Alert

Question: The surgeon performed an incision and drainage for a gluteal abscess while the patient was in the prone position. How should I code for this, considering 00400 seems to be for an anterior approach?


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Answer: You are correct that 00400 (Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; not otherwise specified) is for an anterior approach instead of posterior--which makes it an incorrect choice for your case. Instead, look to 00300 (Anesthesia for all procedures on the integumentary system, muscles and nerves of head, neck and posterior trunk, not otherwise specified).

Extra-unit note: You can sometimes charge additional base units when the physician places the patient in the prone position, to reach a total of five base units for the procedure. You cannot add extra units in this case, however, because the ASA's Relative Value Guide states that 00300 already carries five base units. Answers to You Be the Coder and Reader Questions were provided by Cindy Clark, anesthesia coding supervisor with Anesthesiology Consultants PC in Savannah, Ga.