Anesthesia Coding Alert

Question: After placement of an intra-arterial catheter (A-line) in the operating room (OR), a patient refused surgery. The surgeon and our anesthesiologist spent one hour trying to change her mind. No meds were given. How should I code this situation?

Wyoming Subscriber

Answer: You can charge for the placement of the A-line. You may also be able to report an E/M or consultation code for your physician's services, depending on the documentation available.

Use V64.2 (Persons encountering health services for specific procedures, not carried out; surgical or other procedure not carried out because of patient's decision) for the diagnosis.

Remember to have your anesthesiologist's documentation of the encounter available if you need to appeal or explain to the carrier.