Anesthesia Coding Alert

Question: I have a cosmetic case that cancelled after the pre-op exam but before induction. Do I bill an evaluation and management (E/M) code or the time? The anesthesiologist is telling me that no E/M code is needed because the patient is self-pay. I’m thinking that I should bill the E/M code because the surgery never started due to the patient having afib with uncontrolled rate. Are the rules different for self-pay cases?

New Mexico Subscriber

Answer: Discontinuation of anesthesia before drug administration should be considered an E/M service regardless of the patient’s status (insured vs. non-insured). You cannot waive charges for a self-pay patient if you wouldn’t waive charges to an insured patient.

Take note: If this is a cosmetic surgery that was rescheduled within 48 hours, most practices would not charge for the E/M because the pre-anesthesia assessment will likely be reviewed and re-used when the patient has anesthesia.