Anesthesia Coding Alert

Question: I’m attempting to code anesthesia during a colectomy. Where would the incision be made for a procedure to be considered “upper” from an anesthesia perspective?

Minnesota Subscriber

Answer: The belly button (or umbilicus) is the dividing point between upper and lower abdominal procedures. From a coding perspective, the challenge comes because oftentimes the provider documents “midline incision,” which isn’t as descriptive for code selection.

Remember that the incision location doesn’t matter when you’re choosing codes – you should focus on where the work is performed. In your example of a colectomy, the colon is considered upper abdomen (unless work is exclusively on sigmoid or rectum). You would code the anesthesia with 00790 (Anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; not otherwise specified), which has a base value of 7.