Anesthesia Coding Alert

Question: How is the service performed by Dr. Marcus in a case canceled after induction of anesthesia reported to UnitedHealthcare? What is the appropriate anesthesia procedure code and modifiers, and how much anesthesia time is reported?

Anesthesiologist: Dr. Marcus, personally performed

Anesthesia: General

Diagnosis: Traumatic gunshot wound

ASA: 4

This patient came through the emergency room intubated and was brought into the OR, where general anesthesia was induced with the intention of performing a thoracotomy with exploration. Before the thoracotomy began, the surgeon decided that a Level 1 trauma center was needed. Rescue was called to transport the patient. Anesthesia start time was 22:12 and the end time was 23:28.

Dr. Marcus completed the anesthesia record with monitoring data, woke the patient up from general anesthesia, and made a notation that the case was canceled at the surgeon’s request. No procedure was performed.

Georgia Subscriber

Answer: For the anesthesia procedure code, you’d report 00540 (Anesthesia for thoracotomy procedures involving lungs, pleura, diaphragm, and mediastinum (including surgical thoracoscopy); not otherwise specified). You would append two modifiers to the anesthesia procedure code: Modifier AA (Anesthesia services performed personally by anesthesiologist) and modifier P4 (A patient with severe systemic disease that is a constant threat to life). For the anesthesia time, you’d report 76 minutes.

Why? Because there is no indication that one-lung ventilation was initiated, you would report the anesthesia service using the intended procedure, as the patient was both induced and emerged from anesthesia. In most cases where the patient is put to sleep and awakened, you will not need to report modifier 53 (Discontinued procedure) — anesthesia wasn’t canceled, the surgery was canceled.

The exception to this would be an insurance company policy requiring special reporting for cancellations. In this case, UnitedHealthcare (UHC) is specified as the type of insurance and they indicate that “If surgery is canceled after the Anesthesia Professional has prepared the patient for induction, report the most applicable anesthesia code with full base and time. The Anesthesia Professional is not required to report the procedure as a discontinued service using modifier 53.”

Take note: If the case was canceled prior to the induction of anesthesia and was rescheduled for more than 48 hours later, you may use the anesthesiologist’s preoperative examination to report the appropriate evaluation and management (E/M) service, per UHC’s policy (www.uhcprovider.com/content/dam/provider/docs/public/ policies/comm-reimbursement/COMM-Anesthesia-Policy.pdf).