Anesthesia Coding Alert

Question: A Medicare patient came in for outpatient surgery on his nose and sinuses, but his blood pressure was unexpectedly high. The anesthesiologist conducted the preanesthesia interview and remained with the patient. He took frequent blood pressures, lightly sedated the patient and continued to monitor the patient. Later the physicians decided it was in the patient's best interest to cancel the case. How should I report the case?


Utah Subscriber

Answer: The answer depends on whether the anesthesiologist planned to use MAC (monitored anesthesia care) or general anesthesia during the case. If the case was MAC, report 00160 (Anesthesia for procedures on nose and accessory sinuses; not otherwise specified) with either modifier -53 (Discontinued procedure) or modifier -74 (Discontinued out-patient procedure after anesthesia administration) depending on the circumstances.

If the physician planned to use general anesthesia, report 00160 with modifier -73 (Discontinued out-patient procedure prior to anesthesia administration).