Anesthesia Coding Alert

Question: The anesthesiologist performed the pre-surgical assessment on an inpatient (she is new to our group), but the surgeon delayed the procedure because of risk to the patient. The anesthesiologist completed a detailed assessment, but I don't have specific documentation of his completing a physical exam. How should I report this case?


South Carolina Subscriber

Answer: Your situation is the basis of many long-standing discussions.

Some coders believe that you can report the anesthesiologist's work as a consult because the surgeon canceled the case before it began. If this is appropriate, pick the best inpatient consult code (99251-99255) for the pre-operative assessment. Because the patient you describe is high risk in this case, you-ll report 99255 (Initial inpatient consultation for a new or established patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision-making of high complexity).

Other coders, however, question whether the pre-surgical assessment really counts as a consult. They ask, Where is the request for a consult (opinion), where is the exam, and where is the written report back to the requesting physician?

These coders say you should bill the service as a subsequent hospital visit (99231-99233, Subsequent hospital care, per day, for the evaluation and management of a patient ...) instead, but only if the surgeon does not reschedule the patient within 48 hours. If the surgery takes place within a few days of the pre-operative assessment, the procedure's anesthesia fee includes the work, so you don't report it separately.