Anesthesia Coding Alert

Question: What are the correct surgical and anesthesia codes, modifiers, and diagnosis codes to report for the following case?

Anesthesia: General, ASA: 2

Pre-op Diagnosis: Laboring patient, 39 weeks gestation desires sterilization

Procedure: Laparoscopic tubal ligation

Patient is 38 years old and has Medicaid. The anesthesiologist personally performed anesthesia for tubal ligation after the patient delivered naturally. According to the op report, the occlusion device was inserted laparoscopically into the abdomen, the fallopian tube was pulled into the band applicator, and the occlusion band was pushed off the applicator and placed around the fallopian tube on each side.

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Answer: The correct surgical CPT^® code for laparoscopic tubal ligation using an occlusion device is 58671 (Laparoscopy, surgical; with occlusion of oviducts by device (eg, band, clip, or Falope ring)).

Pay attention to technique: Had electrocautery been used to fulgurate (seal off) each fallopian tube, you would instead submit 58670 (Laparoscopy, surgical; with fulguration of oviducts …).

ASA code: When you crosswalk the surgical code, you’ll find the appropriate anesthesia code is 00851 (Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; tubal ligation/transection). Be sure to submit 00851 with modifier AA (Anesthesia services performed personally by anesthesiologist) appended. Consider including -P2 (A patient with mild systemic disease) after the payment modifier, as some, but not all payers require the informational modifiers.

Diagnosis roundup: The anesthesiologist did not provide any labor analgesia. Because anesthesia was solely used for the tubal ligation, submit Z30.2 (Encounter for sterilization) for the patient’s primary diagnosis.

Since the patient delivered naturally, you should not report a pregnancy-related diagnosis code for the anesthesia services. If you assign a pregnancy diagnosis, this doesn’t affect the patient’s medical history but may cause a denial. Most state Medicaid plans require a signed and dated sterilization consent form and will be looking for a diagnosis related to the sterilization.