Anesthesia Coding Alert

Question: Our anesthesiologist performed a patient's presurgical assessment, but the surgeon canceled the procedure because the patient was too high-risk. The anesthesiologist completed a detailed assessment but didn't specifically document a physical exam. How should I report this case (the patient was an inpatient and new for our group)?


Montana Subscriber

Answer: Anesthesia codes include base units to cover presurgical assessments. But because the surgeon canceled the case instead of simply rescheduling it for the near future, you can submit a claim for the anesthesiologist's assessment.

Because the surgeon initially asked the anesthesiologist to provide anesthesia services instead of a consultation, report the anesthesiologist's visit as subsequent hospital care. Select the appropriate code from 99231-99233 (Subsequent hospital care, per day, for the evaluation and management of a patient ...). Keep the history in case the patient ever does return for surgery, and then the anesthesiologist can complete the remaining  physical assessment.

If you do submit a separate claim for the anesthesiologist's work, include V64.1 (Surgical or other procedure not carried out because of contraindication) as a secondary diagnosis.