Anesthesia Coding Alert

Question: I have a cosmetic case that cancelled after the pre-op exam but before induction. Do I bill an E&M code or the time? The anesthesiologist says that no E/M code is needed because it is self-pay. I'm thinking that I should bill the E/M code because the surgery never started due to patients afib with uncontrolled rate. Are rules different for self-pay cases?

Connecticut Subscriber

Answer: Discontinuation of anesthesia before drug administration would be an E&M regardless of patient status (insured vs. non-insured). You cannot waive charges in a self-pay patient if you wouldn't waive charges to an insured patient. The pre-op exam typically has sufficient information to assign an E/M code.