Anesthesia Coding Alert

Question: Our anesthesiologist was scheduled to administer anesthesia during hardware placement and spinal fusion. He initiated anesthesia and started IONM. Once the orthopedic surgeon saw the findings on the IONM, he decided to abort the procedure. What is the best way to report the anesthesiologist’s service? Do we base the claim on the CPT® codes for the hardware placement and spinal fusion and add modifier 53? Or do we base it on 95939 for the test?

California Subscriber

Answer: Payer recommendations may vary, so the best rule of thumb to follow if your payer DOES NOT have a specific policy regarding a discontinued procedure is to find out when the procedure was discontinued. If the procedure was discontinued before the administration of anesthesia, you may be able to bill an Evaluation and Management (E/M) or consultation code for your provider’s time. However, if the surgery is rescheduled for later that day your anesthesia provider will still be able to use the original pre-anesthesia assessment and should not bill a separate E/M or consultation.

If the surgery was canceled after administration of anesthesia, you would report the service as usual. In your case that would be 00670 (Anesthesia for extensive spine and spinal cord procedures (eg, spinal instrumentation or vascular procedures)) for hardware replacement. The 53 modifier (Discontinued procedure) is not necessary as anesthesia services were not discontinued, the surgery was discontinued. The reduced payment will be based on the anesthesia time being less than expected.