Anesthesia Coding Alert

Question: I'm trying to code anesthesia for a urethrocystoscopy for fulguration of a bladder tumor. The code 00910 is for transurethral procedures (not otherwise specified), but 00912 is for transurethral resection of a bladder tumor. Fulguration is not the same as resection. I can't seem to find the appropriate code. How should I code the anesthesia?

West Virginia Subscriber

Answer: Because you would be coding for an anesthesiologist who is providing sedation but not other anesthesia services or a procedure, you'll submit a moderate sedation code for the case. CPT^® 2017 introduced a new group of moderate sedation codes:

• 99155 – Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intraservice time, patient younger than 5 years of age
• 99156 – ... initial 15 minutes of intraservice time, patient age 5 years or older
• +99157 – ... each additional 15 minutes intraservice time (List separately in addition to code for primary service).

Choose the correct code based on the patient's age and the length of intraservice time. As with other anesthesia services, intraservice time begins with the administration of the sedating agent(s) and ends when the procedure is completed, the patient is stable for recovery status, and the physician or other qualified health care professional providing the sedation ends personal continuous face-to-face time with the patient (according to CPT^® 2017 guidelines).

Extra tip: Before reporting these codes, verify that the anesthesiologist truly provided sedation rather than monitored anesthesia care (MAC).