Anesthesia Coding Alert

Question: For the case below, what are the appropriate anesthesia codes and modifiers (in the correct order) for the anesthesiologist and the CRNA? Documentation supports all medical direction criteria and comorbidities. There were two concurrent cases, including this case. The patient has commercial insurance that accepts HCPCS Level II modifiers.

Anesthesiologist: Dr. F
CRNA: Mary S.
Anesthesia: MAC
ASA: 3

After anesthesia was administered and the patient was comfortable, a 22 French cystoscope was introduced through the urethra into the bladder. The bladder was filled with sterile saline. Following inspection of the bladder, the ureter was catheterized, and a guidewire was introduced through the cystoscope and advanced into and through the ureter to the renal pelvis. The calculus was removed. The ureter was irrigated with normal saline, and the catheter, guidewire, and cystoscope were removed. The patient was transferred to PACU in good condition.

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Answer: First let’s look at the anesthesia code and modifiers involved:

• 00918 (Anesthesia for transurethral procedures (including urethrocystoscopy); with fragmentation, manipulation and/or removal of ureteral calculus)
• QK (Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals)
• QX (CRNA service: with medical direction by a physician)
• P3 (A patient with severe systemic disease)
• QS (Monitored anesthesia care service)

Anesthesiologist: For the doctor, you should report 00918-QK-P3-QS.

CRNA: For the certified registered nurse anesthetist (CRNA), you should report 00918-QX-P3-QS.

Hint: The only difference between the two is that you report QK for the anesthesiologist and QX for the CRNA. Both QK and QX are payment modifiers with a higher value than the physical status modifier (P3), so you report QK or QX in the first position here, unless specific payer policy requires differently.

Modifier P3 is a payment modifier based on the line “ASA: 3” in the sample report. Documentation sometimes uses this format to identify physical status related to the American Society of Anesthesiologists’ (ASA) physical status classification system. You should report P3 in the second position and before QS, which is a statistical/information modifier that does not affect payment.