Introduction

Anesthesia codes are grouped anatomically, beginning with the head. Many of the anesthesia codes indicate" not otherwise specified." This allows the code to be reported for the anatomic area, unless a more specific code exists. For example, code 00920 describes anesthesia for procedures on male genitalia (including open urethral procedures); not otherwise specified.

Selecting an anesthesia code follows the same basic steps as assigning procedure codes for other specialties. Coders either will use the Anesthesia section in the CPT index to locate the correct anatomic area, or turn to the blue Anesthesia 00100-00210 tabbed index and look under the appropriate anatomic heading.

Until the new anesthesia coder becomes familiar with anatomical codes, it is best to use the Anesthesia section to begin learning. Keep in mind that codes are not always found under the surgical description and the coder may need to default backward to find the most accurate description. For example, the code ranges for anesthesia for a simple "mastectomy" are not listed under "mastectomy," but rather under "breast."

Although the liver is located in the upper abdomen, the harvesting of liver is reported with code 01990 Physiological support for harvesting of an organ(s) from a brain-dead patient, which is listed under “Other procedures.”__________________________________________________________________________ Anesthesia "crosswalk" books are available to assist coders by "cross-walking" the known surgical code to an appropriate anesthesia code. When more than one code is suggested by the crosswalk, the coder must determine the code with the highest base unit, which is the most applicable code to report.

Types of Anesthesia

There are three different types of anesthesia: General, Regional, and Monitored Anesthesia Care (MAC):

General Anesthesia-A drug-induced loss of consciousness.

Regional Anesthesia-A loss of sensation in a region of the body, using technique such as:

o Spinal Anesthesiao Epidural Anesthesiao Nerve Block

Monitored Anesthesia Care-An anesthesia service where the patient may be sedated. The anesthesia provider must be qualified to convert to a general anesthetic, if necessary.

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Local anesthesia is not reported using anesthesia codes. Local anesthesia is included in the surgical package and is not reported separately.__________________________________________________________________________

Anesthesia Providers

The anesthesiologist is a physician who is licensed to practice medicine and successfully has completed an accredited anesthesiology program. These physicians may personally perform, medically direct, or medically supervise members of an anesthesia care team.

A certified registered nurse anesthetist (CRNA) is a registered nurse who successfully has completed an accredited nurse anesthesia training program. The CRNA may be either medically directed by an anesthesiologist or non-medically directed.

An anesthesiologist assistant (AA) is a health professional who successfully has completed an accredited Anesthesia Assistant training program. The AA may only be medically directed by an anesthesiologist.

An anesthesia resident is a physician who has completed his medical degree and is currently in a residency program specifically for anesthesiology training.

A student registered nurse anesthetist (SRNA) is a registered nurse who is training in an accredited nurse anesthesia program.

Anesthesia Coding Terminology

One-Lung Ventilation (OLV)-one lung is ventilated and the other lung is collapsed temporarily to improve surgical access to the lung. Several anesthesia codes separately identify utilization of one-lung ventilation.

Pump Oxygenator-when a cardiopulmonary bypass (CPB) machine is used to function as the heart and lungs during heart or great vessel surgery.

Intraperitoneal-within the peritoneum; organs in the upper abdomen include the stomach, liver, gallbladder, spleen, jejunum, ascending and transverse colon. Intraperitoneal organs in the lower abdomen include the appendix, cecum, ileum and sigmoid colon.

Extraperitoneal or Retroperitoneal-behind the peritoneum. Extraperitoneal organs in the lower abdomen include the ureter and urinary tract. The kidneys and adrenal glands and lower esophagus are extraperitoneal organs of the upper abdomen. Also located in the retroperitoneum are the aorta and inferior vena cava.

Radical-extensive and complex surgery intended to correct a severe health threat.

Diagnostic or Surgical Arthroscopic Procedures-may be performed on the temporormandibular, shoulder, elbow, wrist, hip, knee, and ankle. Coders should assign

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a diagnostic code only when no surgical procedure is performed (eg, if a knee arthroscopy is listed as "diagnostic" and a meniscectomy is performed, a surgical arthroscopic code is assigned).

Postoperative Pain Management

Postoperative pain management may be requested by the surgeon and billed separately by the anesthesiologist if the anesthesia for the surgical procedure is not dependent on the efficacy of the regional anesthetic technique.

Nerve block codes, for example 64415 (brachial plexus block), may be used as an adjunct to general anesthesia if placement is for postoperative pain management. Nerve block codes should not be reported separately if the block is the mode of anesthesia for a procedure being performed. For example, if a carpal tunnel procedure is performed with an axillary block, a code from the anesthesia section (01810+ related anesthesia time) is reported. No separate code is reported for the axillary block.

Coding will depend on what is injected, the site of the injection, and placement of either a single injection block or a continuous block by catheter. The CPT code reported should be appended with a modifier 59 Distinct procedural services to signify the service is a separate and distinct from the anesthesia care provided for the surgery.

When ultrasound or fluoroscopic guidance is utilized for pain management procedures and appropriately documented, codes are reported separately with modifier 26 Professional component, unless the code selected includes image guidance (fluoroscopy or CT).

Acute pain diagnosis codes are separately identified in category 338 of the ICD-9-CM codebook.

Continuous catheter codes, for example 64448 Injection, anesthetic agent; femoral nerve, continuous infusion by catheter (including catheter placement), are reported for continuous administration of anesthesia for postoperative pain management. If the infusion catheter is placedfor operative anesthesia, the appropriate anesthesia code plus time is reported. If the continuous infusion catheter is placed for postoperative pain management, the daily postoperative management of the catheter is included in 64448.

Code 01996 Daily hospital management of epidural or subarachnoid continuous drug administration is assigned for daily hospital management of epidural or subarachnoidcontinuous drug administration. Continuous infusion by catheter such as femoral (64448) or sciatic nerve (64446) is not an epidural catheter; therefore, 01996 is not reported with these codes. Anesthesiologists report an appropriate E/M service to re-evaluate postoperative pain if documentation supports the level of service reported and billed.

As with the nerve blocks, the epidural/subarachnoid injection may be either a single injection or a continuous catheter. For example, a continuous infusion in the thoracic area is reported as 62318 Injection, including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (including anesthetic,

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antispasmodic, opioid, steroid, other solution), mot including neurolytic substances, includes contrast for localization when performed, epidural or subarachnoid; cervical or thoracic. When these techniques are used for postoperative pain management, the same rules apply.

When an epidural or subarachnoid catheter is placed for a laboring patient, the injection codes typically are not reported. CPT codes to describe labor epidural/subarachnoid services are listed under the Obstetric section of the anesthesia codes.

Daily hospital management of continuous epidural or subarachnoid drug administration (01996) cannot be reported on the day of the epidural or subarachnoid catheter placement. It may be reported starting with the first postoperative day.

ICD-9-CM Coding

The majority of anesthesia services are provided to patients during surgery. The postoperative diagnosis should be coded because the preoperative diagnosis may change intra-operatively. For example, if a patient is admitted with pain in the right lower quadrant and subsequently has an appendectomy, the postoperative diagnosis may be acute appendicitis.

Supporting diagnosis codes may be reported if they are relevant to either substantiate medical necessity or support physical status modifiers, which will be discussed in the next section.

With few exceptions, diagnosis codes for anesthesia are assigned in the same manner as any other diagnosis:

Identify reason for anesthesia service; Review for other pertinent information and supporting diagnosis codes; Check alphabetic index and then check the code in the Tabular list Locate main entry term Pay attention to notes listed in main terms Understand coding conventions (See ICD Official and Additional Conventions) Look for additional instructions in the tabular (numeric) list Make sure code is to highest level of specificity Assign pertinent related ICD-9-CM coders)

CPT CodingServices included with the base unit value of anesthesia codes reported are:

All usual preoperative and postoperative visits Anesthesia care during the procedure Administration of fluids and/or blood products during the surgery Non-invasive monitoring (ECG, temperature, blood pressure, pulse oximetry,

capnography and mass spectrometry)

Unusual forms of monitoring-for example, arterial lines, central venous (CV) catheters and pulmonary artery catheters (eg, Swan Ganz)-are not included in the base unit value of the anesthesia code.

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Base unit values are not listed separately in CPT. The ASA (American Society of Anesthesiologists) determines the base unit values for anesthesia codes, based on the difficulty of the procedure performed. The ASA and Medicare each publish a list of base unit values.

Determining the base value is the first step in calculating anesthesia charges and payment expected. Time reporting is the second step. Anesthesia time begins when the anesthesiologist begins to prepare the patient for anesthesia in either the operating room or an equivalent area. Pre-anesthesia assessment time is not part of reportable anesthesia time.

Anesthesia time begins when the anesthesiologist begins to prepare the patient for anesthesia in either the operating room or an equivalent area. Pre-anesthesia assessment time is not part of reportable anesthesia time. Anesthesia time ends when the anesthesiologist is no longer in personal attendance, and generally is reported when the patient is safely placed under postoperative supervision. Time reporting on claims may vary, and there is no national guideline. Time units are added to the base unit value as is “customary in the local area.”

Medicare requires exact time reporting without rounding to the nearest five minutes. For example, if anesthesia time starts at 11:02and the patient is turned over to PACU at 11:59, the reported anesthesia time is 57 minutes. Medicare divides the 57 minutes by 15 minuteincrements for total value of 3.8 units. If the procedure has a base value of six (6) units, adding 3.8 units gives a total of 9.8 units, which is then multiplied by the Anesthesia Conversion Factor for the geographic location where the services are provided. Other insurance companies may process the anesthesia time reported in increments that vary-from exact time (like Medicare), to 10, 12 or 15 minutes, or some other time increment.

Multiple (surgical) procedures may be performed on one patient during anesthesia administration. When this occurs, the surgery representing the most complexprocedure is reported because this service carries a higher base unit value. Anesthesia time is reported as usual, from the time the anesthesiologist begins to prepare the patient until the patient is safely placed under postoperative supervision.

The surgical time does not play a role in determining the anesthesia time.________________________________________________________________________

Example:A patient has an inguinal hernia repair (00830, base 4) and a ventral hernia repair (00832, base 6) -only the ventral herniorrhaphy (00832) is reported because it is more complex and has a higher base value than the inguinal hernia surgery. The total time for both procedures is reported as anesthesia time. The diagnosis code related to the ventral hernia is reported in the primary position. Reporting the inguinal hernia diagnosis as secondary may help explain

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why the reported anesthesia time is longer than normally expected for the procedure reported.__________________________________________________________________________

Only one anesthesia code is reported during anesthesia administration except in the case where there is an anesthesia add-on code. For example, the anesthesia section of CPT has add-on codes listed under Burn Excision or Debridement and Obstetric codes. These add-on procedures may not be reported alone; they must be reported with the applicable primary anesthesia code referenced in parenthesis.

For example, add-on code +01953 Anesthesia for second- and third-degree burn excision or debridement with or without skin grafting, any site, for total body surface area (TBSA) treated during anesthesia and surgery; each additional 9% total body surface area or part thereof (List separately in addition to code for primary procedure) is reported if the total body surface area (TBSA) treated during surgery exceeds nine (9%) percent. This add-on code is reported in addition to 01952 Anesthesia for second- and third-degree burn excision or debridement with or without skin grafting, any site, for total body surface area (TBSA) treated during anesthesia and surgery; between 4% and 9% of total body surface area for each additional 9% or part thereof of the TBSA treated.

Therefore, a TBSA of 40% is reported as follows:01952+ TM First 4 to 9% of TBSA +01953x 4 Represents the remaining 31% of TBSA in increments of 9% (the remaining 4% is considered a "part thereof")

Note that the first anesthesia code, 01952 is reported with time units. The add-on code 01953 is reported in units only.

Physical Status Modifiers

Physical status modifiers are anesthesia modifiers that describe the physical status of the patient. These modifiers are not recognized by Medicare for additional payment, and no base values are listed in CPT. But because insurance companies are familiar with the anesthesia coding guidelines in CPT, non-Medicare payers typically pay additional base units.

The following modifiers are assigned to patients based on their individual physical status: P1-A normal healthy patient-No extra value added P2-A patient with mild systemic disease-No extra value added P3-A patient with severe systemic disease-1 extra unit P4-A patient with severe systemic disease that is a constant threat to life-2 extra units P5-A moribund patient who is not expected to survive without the operation-3 extra

units P6-A declared brain-dead patient whose organs are being removed for donor

purposes-No extra value added

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For example, a non-Medicare patient who has a severe systemic disease that is a constant threat to life and is undergoing a direct coronary artery bypass graft (CAB G) with a pump oxygenator is reported as 00567-P4.

Qualifying circumstances (QC) are anesthesia add-on codes assigned to report anesthesia services performed under difficult circumstances that may affect significantly the character of an anesthesia service. ASA assigned base unit values for the qualifying circumstances. The base values are not listed in CPT. These add-on codes are not recognized by Medicare for additional payment.

+99100-Anesthesia for patient of extreme age, younger than one (1) year and older than 70-1 extra unit+99116-Anesthesia complicated by utilization of total body hypothermia-5 extra units+99135-Anesthesia complicated by utilization of controlled hypotension-5 extra units+99140-Anesthesia complicated by emergency conditions (specify)-2 extra units

Documentation must support the qualifying circumstance code(s) reported. An emergency is defined as existing when a delay in the treatment of the patient would lead to a significant increase in the threat to the patient's life or body parts.

Highlight parenthetical notes pertaining to use of qualifying circumstance codes with the CPT code for the anesthesia service. For example, following code 00326,

it states "Do not report 00326 in conjunction with 99100.”_______________________________________________________________________

Coders now should understand the calculation for anesthesia services is BASE + TIME + PHYSICAL STATUS MODIFERS + QUALIFYING CIRCUMSTANCES multiplied by the CONVERSION FACTOR for non-Medicare payers. For Medicare, the calculation for anesthesia services is BASE + TIME multiplied by the Medicare conversion factor for the region.

Additional Billable Items by Anesthesiologist

When the anesthesia provider places invasive monitoring devices, an additional code is reported. Monitoring is included in the base value, so if another provider-such as the surgeon or a perfusionist-places the line or catheter, no additional information is reported by the anesthesia provider on the claim form. The anesthesia providers may only report service(s) they perform.

Time is not reported separately for "flat fee" procedures. Unlike anesthesia codes that require anesthesia time be documented and reported, these codes are found in the surgery section of the CPT and no time is associated for reporting or payment.

The most common codes reported in addition to the anesthesia service are:

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31500- Intubation, endotracheal, emergency procedure:Emergency intubation may be reported separately when an anesthesia provider is requested tointubate a patient who is NOT undergoing anesthesia. Normal intubation for patients undergoing anesthesia is included in the base value of the anesthesia code.

36620-Arterial Catheterization or cannulation for sampling, monitoring or transfusion (separate procedure); percutaneous:(placed in a radial artery "through" needle puncture of the skin).

36555 or 36556-Insertion of non-tunneled central venous catheter: Because these codes are age-related, the appropriate code assignment is based on whether the patient is under five (5) years of age or over.

93503-Insertion and placement of flow directed catheter (eg, Swan-Ganz) for monitoring purposes

For example, anesthesia coders will look for documentation to support placement of a pulmonary artery catheter by the anesthesia provider. It may be identified as either a PAC (pulmonary artery catheter) or SG (Swan-Ganz), and should have procedural notes documented in either the comments section of the anesthesia record, in progress notes, or on a separate procedure form.

Moderate Sedation

Moderate sedation can be provided by a physician other than the surgeon; and an anesthesiologist may provide moderate sedation in these circumstances. Moderate sedation is provided without an anesthesia machine and backup for general anesthesia. In addition, moderatesedation codes do not include minimal sedation, deep sedation, or monitored anesthesia care. Coders are directed to the anesthesia section of the CPT to report services. Only anesthesia providers report anesthesia codes.

Monitored Anesthesia Care (MAC) is distinctly different from moderate sedation. MAC may vary from a "light" to "deep" sedation, based on each patient's health status. The patient's anesthesia plan is determined on a case-by-case basis. When using MAC, the anesthesia providermust be qualified and prepared at all times to convert to general anesthesia, if necessary. MAC services are paid in the same way as general or regional anesthesia services - although many insurance companies request special modifiers to identify the service as monitored anesthesia care. We will discuss MAC and these modifiers more completely in the Healthcare Common Procedure Coding System (HCPCS) section.

CPT Modifiers

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Modifier 23 Unusual anesthesia-reported to describe a procedure that usually doesn't require anesthesia but, due to unusual circumstances, is performed under general anesthesia. For example, a pediatric patient may require general anesthesia for the surgeon to perform aprocedure that may not require anesthesia under usual circumstances.

Modifier 47 Anesthesia by surgeon-reported by the surgeon when he also provides regional or general anesthesia for the surgical service. Anesthesia providers do not report this modifier. Modifier 47 should not be appended to anesthesia codes (00100-01999).

Modifier 53 Discontinued procedure-be reported to describe a procedure that was started and, due to extenuating circumstances, was discontinued.

Modifier 59 Distinct procedural service-used to indicate that a procedure or service is distinct or independent from other non-evaluation and management procedures. Documentation must support a different session, procedure, surgery, site, organ system, incision/excision, or injury. This modifier is often appended to post-operative pain management services to indicate it is separate from the anesthesia administered during the surgery.

Modifier 73 Discontinued out-patient hospital/ambulatory surgery center (ASC) procedure prior to the administration of anesthesia-approved for ASC and hospital outpatient use; carrier policy often identifies this as the modifier to report when anesthesia services are discontinued prior to administration of anesthesia. Note: physician reporting of discontinued procedures isreferred to modifier 53.

Modifier 74 Discontinued outpatient hospital/ambulatory surgery center (ASC) procedure after administration of anesthesia-approved for ASC and hospital outpatient use. Although this modifier is not strictly anesthesia related, carrier policy often identifies this as the modifier to report when anesthesia services are discontinued after administration of anesthesia. Note: physician reporting of discontinued procedures is referred to modifier 53.

Direction, Supervision, and Monitoring Medical direction occurs when an anesthesiologist is involved in two, three, or four anesthesia procedures at the same time; or a single anesthesia procedure with a qualified CRNA or anesthesiologist assistant.

According to the Centers for Medicare & Medicaid Services (CMS), when an anesthesiologist is medically directing, he or she must:

1. Perform a pre-anesthetic examination and evaluation;2. Prescribe the anesthesia plan;3. Personally participate in the most demanding procedures of the anesthesia plan including, if applicable, induction and emergence;4. Ensure that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist;

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5. Monitor the course of anesthesia administration at frequent intervals;6. Remain physically present and available for immediate diagnosis and treatment of emergencies; and7. Provide the indicated post anesthesia care.

If one (or more) of the above services is not performed by the anesthesiologist, the service is not considered medical direction.

While medically directing, anesthesiologists should not be providing services to other patients. However, anesthesiologists are allowed to provide the following to other patients without affecting their ability to provide medical direction:

Addressing an emergency of short duration in the immediate area Administering an epidural or caudal anesthetic to ease labor pain Periodic rather than continuous monitoring of an obstetrical patient Receiving patients entering the operating suite for the next surgery Checking on or discharging patients from the post anesthesia care unit Coordinating scheduling matters

Medical supervision occurs when an anesthesiologist is involved in five or more anesthesia procedures during the same time; or when the required services listed under medical direction above are not performed by the anesthesiologist.

Non-medically directed CRNAs are working without medical direction.

MAC is the intraoperative monitoring by an anesthesiologist or qualified individual under the direction of an anesthesiologist of a patient's vital physiological signs, in anticipation of:

The need for administration of general anesthesia;or

The development of an adverse physiological patient reaction to the surgical procedure.

Monitored anesthesia care includes the performance of the following by the anesthesiologist or qualified individual under the direction of an anesthesiologist:

Pre-anesthetic examination and evaluation Prescription of the anesthesia care required Completion of an anesthesia record Administration of any necessary oral or parenteral medication Provision of indicated postoperative anesthesia care

The anesthesiologist, CRNA or a qualified individual under the medical direction of an anesthesiologist, must be continuously present to monitor the patient and provide anesthesia care.

Medical direction modifiers from HCPCS Level II (discussed below) allow reporting of the appropriate medical direction/supervision/non-medically directed status.HCPCS Level II Modifiers

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The following personally performing, medical supervision and medical direction modifiers are reported only with anesthesia CPT codes:

AA-Anesthesia services performed personally by anesthesiologist AD-Medical supervision by a physician: More than four concurrent anesthesia

procedures

Note: "Concurrency" refers to all current ongoing anesthesia cases during the same time under the direction or supervision of an anesthesiologist.

QK-Medical direction of 2, 3, or 4 concurrent anesthesia procedures involving qualifiedindividuals

QY-Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist

GC-This service has been performed in part by a resident under the direction of a teaching physician

The following medical supervision/direction modifiers are reported with CRNA or Anesthesiologist Assistant services:

QX-CRNA service: With medical direction by a physician QZ-CRNA service: Without medical direction by a physician

The state “scope of practice” may prohibit an anesthesiologist assistant (AA) from reporting claims with a non-medical direction modifier. The AD modifier only applies to the anesthesiologist. The CRNA would report QX if medical direction is broken by theanesthesiologist because the CRNA would not know the status of other cases.

Medical direction modifiers are associated with specific providers and are reported in the first position after the anesthesia CPT code because payment often is related to the modifier reported.

Additional anesthesia-related modifiers usually are reported in the second position after any related medical direction modifiers; they are considered informational or statistical. Modifiers affecting payment always should be reported in the position before information/statistical modifiers.

Physical status modifiers (already discussed) also are reported in the second or third position, as applicable.

Example:

1. 00910-AA-P3 (to report a personally performing physician service with a physical status 3 patient)

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2. 00142 QK-QS-P3 and 00142 QX-QS-P3 (to report the medically directing physician and CRNA service with a physical status 3 patient under monitored anesthesia care).

When reporting MAC services, CMS and other insurance carriers may require the use of one of the following:

QS-Monitored anesthesia care service G8-Monitored anesthesia care for deep complex, complicated, or markedly invasive

surgical procedure G9-Monitored anesthesia care for patient who has a history of severe

cardiopulmonary disease

When reporting modifier G8 or G9, it is not necessary to report a QS modifier separately because the description of these modifiers includes MAC.

Most anesthesia modifiers are reported only with anesthesia codes; they are not listedwith other CPT code categories.

Anesthesia-Related Teaching Rules

To interpret Medicare's teaching rules for anesthesia correctly, the following italicizedteaching information is taken directly from chapter 12, section 50 on the Medicare On-Line Manual at www.cms.gov/manuals/downloads/clm104cl2.pdf. The chapter should be reviewed in its entirety before billing anesthesia services to Medicare.

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Payment at Personally Performed RateThe Part B contractor must determine the fee schedule payment, recognizing the base unitfor the anesthesia code and one time unit per 15 minutes of anesthesia time if:

The physician personally performed the entire anesthesia service alone;

The physician is involved with one anesthesia case with a resident, the physician is a

teaching physician as defined in §100, and the service is furnished on or after January 1, 1996; The physician is

involved in the training of physician residents in a single anesthesia case, two concurrent anesthesia cases involving residents or a single anesthesia case involving a resident that is concurrent to another case paid under the medical direction rules. The physician meets the teaching physician criteria in §100.1.4 and the service is furnished on or after January 1, 2010;

The physician is continuously involved in a single case

Glossary

Add-on Codes-Procedures that commonly are carried out in addition to the primary procedure performed. Add-on codes may not be reported alone, and are identified with a + sign.

Anesthesiologist Assistant-A health professional who has completed successfully an accredited anesthesia assistant training program.

Anesthesiologist-A physician who is licensed to practice medicine and has successfully completed an accredited anesthesiology program.

Anesthesia Time- Begins when the anesthesiologist (or anesthesia provider) begins to prepare the patient for the induction of anesthesia and ends when the anesthesiologist (or anesthesia provider) is no longer in personal attendance.

Arterial Line-A catheter inserted into an artery. It is used most commonly to measure real-time blood pressure and to obtain samples for arterial blood gas.

Base Unit Value-Value assigned to anesthesia codes for anesthetic management of surgery and diagnostic tests. Base unit values will vary depending on the difficulty of the surgery, and thus the administration of anesthesia.

Cardiopulmonary Bypass (CPB)-A technique that is used during heart surgery to take over temporarily the function of the heart and lungs.

CRNA(Certified Registered Nurse Anesthetist)-A registered nurse who has completed an accredited nurse anesthesia training program successfully.

Controlled Hypotension-A technique used in general anesthesia to reduce blood pressure to control bleeding during surgery. Watch anesthesia record for notes regarding deliberate or controlled hypotension.

Conversion Factor-A unit multiplier to convert anesthesia units into a dollar amount for anesthesia services. Conversion Factors are reviewed annually by CMS and vary geographically. Conversion Factors also may be negotiated with insurance companies.

Central Venous Catheter-A catheter placed in a large vein such as the internal jugular, subclavian, or femoral vein with the tip of the catheter close to the atrium, or in the right atrium of the heart.

CVP(Central Venous Pressure)-A direct measurement of the blood pressure in the right atrium and vena cava. CVP reflects the amount of blood returning to the heart and the ability of the heart to pump the blood from the right heart into the pulmonary system.

Emergency-A delay in treatment would lead to significant increase in the threat to life or body part.

Flat Fee-A flat fee is based on the physician fee schedule. Payments are made under the Relative Value Unit, rather than by Conversion Factor. Time is not a consideration for payment. Examples are arterial lines, CV lines, Emergency Intubation, and Swan Ganz catheter insertion.

General Anesthesia-A drug-induced loss of consciousness during which patients cannot be aroused.

Hypothermic Circulatory Arrest-Implies a temperature of 20 degrees centigrade or less.

Medical Direction-Occurs when an anesthesiologist is involved in two, three, or four concurrent anesthesia procedures, or a single anesthesia procedure with a qualified anesthetist. CMS and other carriers publish criteria that must be met to report medical direction.

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Payment at Personally Performed RateThe Part B contractor must determine the fee schedule payment, recognizing the base unitfor the anesthesia code and one time unit per 15 minutes of anesthesia time if:

The physician personally performed the entire anesthesia service alone;

The physician is involved with one anesthesia case with a resident, the physician is a

teaching physician as defined in §100, and the service is furnished on or after January 1, 1996; The physician is

involved in the training of physician residents in a single anesthesia case, two concurrent anesthesia cases involving residents or a single anesthesia case involving a resident that is concurrent to another case paid under the medical direction rules. The physician meets the teaching physician criteria in §100.1.4 and the service is furnished on or after January 1, 2010;

The physician is continuously involved in a single case

Medical Supervision-Occurs when an anesthesiologist is involved in five or more concurrent anesthesia procedures, or fails to meet required medical direction criteria.

Monitored Anesthesia Care-Refers to a continuum of sedation ranging from light to deep. Anesthesia provider must be prepared to convert to a general anesthesia, if necessary.

PAC-Pulmonary Artery Catheter (eg, Swan Ganz)-A flow directed catheter inserted into thepulmonary artery. PACs are used to measure pressures and flows within the cardiovascular system.

Physical Status modifier-A modifier used to report the physical status assigned to each patient undergoing anesthesia. Patients are ranked by their individual health status.

Pump Oxygenator-Term used when a cardiopulmonary bypass (CBP) machine is used to function as the heart and lungs during heart surgery.

Qualifying Circumstances-Circumstances that significantly affect the character of an anesthesia service. These add-on procedures may be reported only with anesthesia codes. More than one may be reported, if applicable. Qualifying circumstances may not be reported separately when a code descriptor already indicates the circumstance.

Regional Anesthesia-Loss of sensation in a region of the body, produced by application of an anesthetic agent.

Relative Value Unit-A unit measure used to assign a value to services. It is determined by assigning weight to factors such as physician work, practice expense and malpractice expense.

Resident-A physician who has completed his and her medical degree and entered a residency program specifically for anesthesiology training.

SRNA (Student Registered Nurse Anesthetist)-A registered nurse who is training in an accredited nurse anesthesia program.

Surgical Field Avoidance-Anesthesia provider avoids an area where the surgeon is working (usually on procedures around the head, neck or shoulder girdle). The ASA assigned a minimum base unit value of" 5" for procedures requiring field avoidance.

Total Body Hypothermia-Deliberate reduction of a patient's total body temperature, which reduces the general metabolism of the tissues. Watch anesthesia record for notes regarding total body hypothermia. Generally, temperature is reduced 20 percent to 30 percent below a patient's normal temperature. This may not be reported separately when code indicates it is included.

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Payment at Personally Performed RateThe Part B contractor must determine the fee schedule payment, recognizing the base unitfor the anesthesia code and one time unit per 15 minutes of anesthesia time if:

The physician personally performed the entire anesthesia service alone;

The physician is involved with one anesthesia case with a resident, the physician is a

teaching physician as defined in §100, and the service is furnished on or after January 1, 1996; The physician is

involved in the training of physician residents in a single anesthesia case, two concurrent anesthesia cases involving residents or a single anesthesia case involving a resident that is concurrent to another case paid under the medical direction rules. The physician meets the teaching physician criteria in §100.1.4 and the service is furnished on or after January 1, 2010;

The physician is continuously involved in a single case

Chapter Review Questions

1. An epidural is considered which type of anesthesia?A. LocalB. MAC

C. RegionalD. General

2. Which of the following is separately billable and is NOT included in anesthesia services?A. Pre-operative visitsB. Blood pressure monitoring

C. Blood transfusionD. Introduction of an arterial line

3. A healthy 79-year-old male patient with communicating hydrocephalus undergoes a creation of a ventriculo-peritoneal shunt. What is the correct anesthesia code for this procedure?A. 00220-P1, 99100B. 00220-P1

C. 00210-P1D. 00210-Pl, 99100

4. A 42-year-old with renal pelvis cancer receives general anesthesia for a laparoscopic radical nephrectomy. The patient has controlled type II diabetes otherwise no other co-morbidities. What is the correct CPT and ICD-9-CM code for the anesthesia services?A. 00860- P1, 189.0, 250.00B. 00840-P3, 189.1, 250.00

C. 00862-P2, 189.1, 250.00D. 00868-P2, 198.0, 250.00

5. A healthy 32-year-old with a closed distal radius fracture received monitored anesthesia care for an ORIF of the distal radius. What is the code for the anesthesia service?A. 0l830-P1B. 01860-QS-P1

C. 01830-QS-P1D. 01860-QS-G9-P1

6. A l0-month-old child is taken to the operating room for removal of a laryngeal mass. What is the appropriate anesthesia coder(s)?A. 00320B. 00326

C. 00320, 99100D. 00326, 99100

7. A patient receiving radiation therapy for a brain tumor requires anesthesia. What is the correct anesthesia code?A. 01922B. 01924

C. 01930D. 01933

8. A 50-year-old female had a left subcutaneous mastectomy for cancer. She now returns for reconstruction which is done with a single TRAM flap. Right mastopexy is done for asymmetry. Code the anesthesia for this procedure.A. 00404B. 00402

C. 00406D. 00400

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Answers:

1. C 2. D 3. A 4. C 5. C 6. B 7. A 8. B