Anesthesia Coding Alert

Question: What are the correct surgical and anesthesia codes, modifiers, and diagnosis codes to report for the doctor and certified anesthesiologist assistant (CAA) in the following case? Also, how many minutes of anesthesia time should be reported?

Anesthesiologist: Dr. Howard and CAA
Anesthesia: Monitored anesthesia care (MAC); ASA 2
Preop Diagnosis: Emergency services for abdominopelvic pain, unspecified trimester
Postop Diagnosis: Retroverted uterus, first trimester
Procedure: Hysteroplasty, 58540
This patient is a 22-year-old female who presented to the emergency room last night with mild abdominopelvic pain. She and her husband were concerned, as she is pregnant. After a physical examination and ultrasound, the emergency room physician found retroversion of gravid uterus and added her to the surgery schedule for the following day with Dr. Kristofferson.
According to the anesthesia record, Dr. Howard performed a pre-anesthesia evaluation and plan for MAC for a uterus repair at 6:21. Anesthesia time started at 7:01 and ended at 7:36 when the patient was transferred to PACU. Dr. Howard signed the PACU documentation at 8:01, noting there were no complications with anesthesia.

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Answer: In this case, you’ll report the postoperative diagnosis code. Although the preop diagnosis indicates this was an emergency, the ER physician scheduled the patient for surgery the following day — an emergency surgery would have been performed immediately.

ICD-10-CM: The postop diagnosis identified both the trimester and the ER doctor’s findings and is reported with O34.531 (Maternal care for retroversion of gravid uterus, first trimester).

ASA code: When you crosswalk the surgical code 58540 (Hysteroplasty, repair of uterine anomaly (Strassman type)), you’ll find the appropriate anesthesia code is 00840 (Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; not otherwise specified).

Medicare does not require physician presence at induction or emergence. Since Dr. Howard performed the pre- and post-anesthesia evaluations, and the surgery was less than one hour, the documentation meets the requirements for medical direction. So, for Dr. Howard, submit 00840 with modifier QK (Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals) appended. Add modifiers P2 (A patient with mild systemic disease) and QS (Monitored anesthesia care service) after the payment modifier. For the CAA, report 00840 and append modifiers QX (Qualified nonphysician anesthetists service: with medical direction by a physician), P2, and QS.

The anesthesia time reported is from 7:01 to 7:36, which equates to 35 minutes. Remember, the pre- and post-evaluation time is included in the base value for anesthesia services.

Coding note: A retroverted uterus may not cause problems during pregnancy, and this patient’s uterus was repaired. If you missed the P2 modifier, per the American Society of Anesthesiologists (ASA) guidelines, “Although pregnancy is not a disease, the parturient’s physiologic state is significantly altered from when the woman is not pregnant, hence the assignment of ASA 2 for a woman with uncomplicated pregnancy” (www.asahq.org/standards-and-practice-parameters/statement-on-asa-physical-status-classification-system).