Anesthesia Coding Alert

Question: Our anesthesiologist was “in attendance” during an inpatient surgery but never administered anesthesia. He completed an evaluation form on the patient and the surgeon’s operative report mentions that “anesthesia was in attendance” during the procedure. Unfortunately, the patient developed acute tachycardia during procedure and died. Can we code for being “in attendance” during the procedure (the total documented time for our anesthesiologist was 53 minutes)?

Florida Subscriber

Answer: Yes, you can bill for the anesthesiologist’s time. Anesthesia time is not just about providing anesthesia; the time starts when the anesthesia provider begins to prepare the patient for the anesthesia care in the operating room. Since the anesthesiologist had completed the patient evaluation and documented a total time of 53 minutes, you can bill for the services.

Submit a claim for 53 minutes of anesthesia care. In most scenarios you should report code 00731 (Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum; not otherwise specified). Depending on the circumstances, you might sometimes report 00732 (Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum; endoscopic retrograde cholangiopancreatography (ERCP)) instead.

In either case, include the AA modifier (Anesthesia services performed personally by anesthesiologist) or when an anesthetist assists a physician in the care of a single patient to indicate that the anesthesiologist provided the care.

Remember: When preparing to code this situation, don’t forget another important issue: risk management. The patient died while being monitored by anesthesia, which means the anesthesia provider could potentially be subject to a lawsuit. Ensure that your provider’s documentation supports all his involvement and contact your malpractice carrier regarding any potential issue.