Anesthesia Coding Alert

Question: What are the correct diagnosis and anesthesia codes and modifiers for the anesthesiologist in the following case? Also, which physician’s name should be reported on the claim?

Anesthesiologist: Dr. Ken Smith and Dr. Grace Jones

Anesthesia: General; ASA 3

Postop diagnosis: Right renal cysts

Procedure: Laparoscopic ablation of renal cyst, 50541

This patient is a 36-year-old male. Dr. Smith documented poorly controlled Type 2 diabetes with unspecified complications and morbid obesity with a BMI of 42.

The surgeon ablated multiple renal cysts laparoscopically. According to the medical record, Dr. Smith performed the preanesthesia evaluation and plan. Dr. Jones was the anesthesiologist for the surgery. Dr. Jones signed the PACU documentation, noting there were no complications with anesthesia.

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Answer: In this case, you may report codes for the documented comorbidities in addition to the code for the postoperative diagnosis, depending on the payer.

ICD-10-CM: For the postop diagnosis, submit N28.1 (Cyst of kidney, acquired). For the comorbidities use:

• E11.8 (Type 2 diabetes mellitus with unspecified complications)
• E66.01 (Morbid (severe) obesity due to excess calories)
• Z68.41 (Body mass index [BMI] 40.0-44.9, adult)

Make sure to read the code descriptions for Z68.4- carefully, as Z68.41 applies to patients with a BMI of 40 to 44.9 and Z68.42 (Body mass index [BMI] 45.0-49.9, adult) applies to patients with a BMI of 45 to 49.9.

ASA code: When you crosswalk the surgical code 50541 (Laparoscopy, surgical; ablation of renal cysts) you’ll find the appropriate anesthesia code is 00862 (Anesthesia for extraperitoneal procedures in lower abdomen, including urinary tract; renal procedures …). Append modifier AA (Anesthesia services performed personally by anesthesiologist) and add -P3 (A patient with severe systemic disease) after the payment modifier.

Anesthesiologists in a group practice may share pre- and postanesthesia documentation components. Although Dr. Smith performed the preanesthesia evaluation, Dr. Jones was the anesthesiologist for the surgery, and you should report the claim in her name.