Anesthesia

CHAPTER 14


Anesthesia





Anesthesia


Anesthesia is the administration of drugs to induce the loss of the ability to sense pain. Often, the term “anesthesia” is used to refer to general anesthesia, but the term also includes regional, local with intravenous sedation, and local anesthesia. An anesthetist is a specialist in perioperative medicine who provides care to a patient prior to, during, and immediately after surgery. This care includes the evaluation and preparation of a patient for anesthesia service. The anesthetist plans the type of anesthesia and then cares for the patient during the surgical procedure by monitoring blood pressure, heart rate and rhythm, breathing, temperature, kidney function, and level of consciousness and analgesia. The anesthetist can also administer drugs for analgesia (pain relief) before, during, and after the procedure.


Additionally, the anesthetist is responsible for any adjustments to the anesthesia plan, medications, fluids (blood volume and electrolytes), and other parameters to ensure a pain-free and safe surgical experience for the patient. The anesthetist provides postoperative care during the patient’s time in the recovery room. The anesthetist may be a physician (anesthesiologist, also referred to as MDA [Medical Doctor of Anesthesia]) or a nonphysician practitioner trained to administer anesthesia, such as a CRNA (Certified Registered Nurse Anesthetist).



Types of anesthesia


Anesthesia commonly refers to general, regional, local with IV sedation, and local. These types of anesthesia, as well as Monitored Anesthesia Care (MAC), are summarized in the following pages. General anesthesia is a state of total unconsciousness resulting from the administration of a variety of drugs that can produce different effects to ensure unconsciousness, amnesia, analgesia, and muscle relaxation. Many general anesthetics are gases or vapors administered by mask or endotracheal tube (ET, a tube inserted through the nose or mouth into the trachea) along with intravenous medications. Regional or conduction anesthesia includes central and peripheral techniques that block nerves to large areas or body parts:



Central technique






Intravenous regional technique (bier block)




Local anesthesia is the application of an anesthetic agent directly to the area. Local anesthesia techniques include:



MAC does not specifically describe minimal, moderate, or deep sedation. Rather, it is a service in which an anesthesiologist cares for a patient during a diagnostic or therapeutic procedure. It includes a pre-op, intra-op, and post-op service. MAC providers must be qualified and credentialed to perform anesthesia services and be prepared to convert to general anesthesia if necessary. MAC includes assessment and management of potential problems that might occur during the procedure, including rescuing the patient’s airway should it be compromised by drugs that may have been administered. MAC includes support of the patient’s vital functions and may include administration of necessary sedatives, anesthetics, or analgesics. MAC includes postprocedural services as well, such as returning the patient to full consciousness and management of pain side effects that may have resulted from medications administered during the procedure.



Anesthesia care and bundled services/procedures


The various types of anesthesia care have been reviewed, and now it is time to review the various component services/procedures that are considered integral to the anesthesia care. Procedures that are not bundled into the anesthesia codes and may be reported separately are discussed in the subsection below in Anesthesia Care and Separately Reported Services.


Anesthesia care includes the following services:



These services are included in the anesthesia code and are not reported separately.


Anesthesia services are reported with CPT codes 00100-01999 with modifiers that describe the patient’s physical status, concurrency, and other factors that affect anesthesia care and reimbursement. The Anesthesia section of the CPT manual is used by the anesthesiologist/anesthetist to report the provision of anesthesia services. In addition to the 00100-01999 codes, Qualifying Circumstances that affect the anesthesia care are reported with CPT codes 99100-99140. The Qualifying Circumstances codes are located in the Medicine Section, as well as the Anesthesia Section, of the CPT manual and will be addressed a little later in this chapter.


When anesthesia is administered by the physician/surgeon who also performs the procedure/surgery, the anesthesia CPT codes are not used. Rather, the physician reports the anesthesia service by appending modifier -47 to the CPT code that describes the diagnostic or surgical procedure performed.


Anesthesia codes are divided first by anatomic site and then by the specific type of procedure. The last four subsections in Anesthesia—Radiological Procedures, Burn Excisions or Debridement, Obstetric, and Other Procedures—are not by anatomic division. The Radiological Procedures codes are used to report anesthesia services when radiologic services are provided to the patient for diagnostic or therapeutic reasons.


To select the correct anesthesia CPT code, the operative report is essential. Based on the operative report, the coder determines the procedure(s) performed. The correct CPT is selected by referencing the index of the CPT manual and then the code in the Anesthesia section. The coder may also have access to the American Society of Anesthesiologists (ASA) Crosswalk or an encoder with the crosswalk embedded. A crosswalk is a document that indicates which CPT anesthesia codes are reported with the various CPT procedure codes. The coder enters the CPT procedure code and the crosswalk will display the anesthesia code that corresponds to that particular CPT procedure code.


When multiple procedures are performed, with the aid of the ASA Relative Value Guide, the coder determines which code carries the highest base unit value and assigns that code. Only one anesthesia code can be reported when multiple procedures are performed.



Anesthesia care and separately reported services


Additional services/procedures may be performed during anesthesia care and may be reported separately. These include, but are not limited to:



The time spent performing these separately reportable (billable) services must not be included in the time reported for the anesthesia. For example, the time to establish a Swan Ganz catheter is reported separately, and therefore the time it took to establish the catheter placement is not included in the total anesthesia time.


When an epidural is used specifically for postoperative pain control, it is separately reported with 62318 or 62319. There must be an order from the surgeon requesting post-op pain management by the anesthesiologist to report the service. The documentation in the medical record must indicate the medical necessity and the intent for postoperative pain management. The time spent providing the epidural procedure is reported separately and therefore not included in the anesthesia total time. If, however, a nerve block is used as the means to provide regional anesthesia for the performance of the surgical procedure, then the nerve block is not reported separately but is considered included in the anesthesia care (00100-01999).


If an epidural catheter is used to provide regional anesthesia during a procedure and is left in place for postoperative pain control, it is not reported separately. The daily management of the epidural (01996) on a subsequent day after surgery can be reported separately.


Codes from the Evaluation and Management and the Surgery sections of the CPT manual are used to report pain management and critical care services/procedures. The assignment of these codes will be discussed later in this chapter.




Physical status modifiers


The second type of modifying unit used in the Anesthesia section is the Physical Status Modifiers. These modifiers are used to indicate the patient’s condition at the time anesthesia was administered. The Physical Status Modifier not only indicates the patient’s condition at the time of anesthesia but also identifies the level of complexity of services provided. For instance, anesthesia service to a gravely ill patient is much more complex than the same type of service to a normal, healthy patient. The Physical Status Modifier is not assigned by the coder; rather, it is determined by the anesthesiologist and documented in the anesthesia record. The Physical Status Modifier begins with the letter “P” followed by a number from 1 to 6. The relative value for -P1, -P2, and -P6 is zero because these conditions are considered not to affect the service provided.






















P1 Normal healthy patient (0 base units)
P2 Patient with mild systemic disease (0 base units)
P3 Patient with severe systemic disease (1 base unit)
P4 Patient with severe systemic disease that is a constant threat to life (2 base units)
P5 Moribund patient who is not expected to survive (3 base units)
P6 Declared brain-dead patient whose organs are being removed for donor purposes (0 base units)

Every anesthesia code reported must have an accompanying Physical Status Modifier, whereas Qualifying Circumstances codes may or may not be reported (see below).



Concurrent care modifiers


Some third-party payers require additional modifiers to indicate how many cases an anesthesiologist is directing or supervising at one time. A certified registered nurse anesthetist (CRNA) may administer anesthesia to patients under the direction of a licensed physician, or they may work independently depending on the state law. When an anesthesiologist is directing the provision of anesthesia in more than one case at a time, modifiers are used to indicate the context and number of cases that are being reported concurrently (at the same time). Medical direction is when an anesthesiologist is directing CRNAs or AAs (anesthesia assistants) while 2-4 cases are performed concurrently. Medical supervision is when CRNAs or AAs are administering anesthesia in more than four concurrent cases and the anesthesiologist is not present on induction or present to perform oversight/direction for the cases. Also, if there are four concurrent cases being performed and the anesthesiologist is providing medical direction but is called away (such as for an emergency intubation), the medical direction by the anesthesiologist ends, and the medical supervision begins because the anesthesiologist is no longer available to direct the cases.


The MDA’s medical direction is reported with -QY or -QK modifier, and medical supervision is reported with modifier -AD. The CRNA service, whether directed or supervised, would be reported with modifier -QX. The CRNA service would be reported as medical direction regardless of the number of concurrent procedures directed or supervised by the anesthesiologist. The CRNA is always reimbursed at the medically directed rate as long as the anesthesiologist is involved with the CRNA in providing the anesthesia service.


Sometimes the services of two anesthetists (both MDA and CRNA) are medically necessary. Examples of situations requiring two anesthetists would be when managing an emergency patient during surgery, a patient has severe multiple injuries, a patient with a ruptured AAA (abdominal aorta aneurysm), etc. In these cases, the MDA’s services are considered to be personally performed (-AA required), and the CRNA’s services are considered to be independently performed (-QZ required).


The following modifiers are among the most commonly used:






















-AA Anesthesia services performed personally by anesthesiologist
-AD Medical supervision by a physician: More than four concurrent anesthesia procedures
-QK Medical direction of two, three, or four concurrent anesthesia procedures involving a qualified individual
-QX Certified registered nurse anesthetist (CRNA) service, with medical direction by a physician
-QY Anesthesiologist medically directs one CRNA
-QZ CRNA service, without medical direction by a physician
































Concurrency Scenarios Who Reports Modifier Appended
Personally performed by an MDA MDA -AA
MDA and CRNA services are each medically necessary in anesthesia care MDA
CRNA		 -AA
-QZ
MDA medically directing 1 CRNA MDA
CRNA		 -QY
-QX
MDA medically directing CRNAs during 2-4 concurrent cases MDA
CRNA		 -QK
-QX
MDA medically supervising a CRNA (either >4 concurrent cases or the MDA is performing procedure that does not allow for involvement required at the medically directed rate) MDA
CRNA		 -AD
-QX
CRNA without medical direction CRNA -QZ



Qualifying circumstances


At times, anesthesia is provided in situations that make the administration of the anesthesia more difficult. These types of cases include those that are performed in emergency situations and those dealing with patients of extreme age and include services performed during the use of controlled hypotension (low blood pressure) or the use of hypothermia (low body temperature). The Qualifying Circumstances codes are five digits that begin with 99 and are add-on codes that cannot be used alone but must be used in addition to another code. The Qualifying Circumstances codes are used only to provide additional information and are reported in addition to the anesthesia procedure code.


The Qualifying Circumstances codes are located in two places in the CPT manual—the Medicine section and the guidelines of the Anesthesia section. In both locations, the plus symbol is located before the codes (99100-99140) to indicate their status as add-on codes.


In some cases, more than one Qualifying Circumstances code may apply and can be reported. For example, a surgical procedure performed on a patient of extreme age (99100) in which the anesthesia is complicated by an emergency condition (99140). The Qualifying Circumstances codes are not subject to the concurrency and physical status modifiers.


There are differing payer guidelines for qualifying circumstances. For example, some payers may limit the reporting of qualifying circumstances to only the directing anesthesiologist. Throughout this chapter, apply this limitation when reporting Qualifying Circumstances.


The Qualifying Circumstances codes are as follows:




















CPT Definition
99100 Anesthesia for patient of extreme age, younger than 1 year, or older than 70
99116 Anesthesia complicated by utilization of total body hypothermia
99135 Anesthesia complicated by utilization of controlled hypotension
99140 Anesthesia complicated by emergency conditions



Calculation of charge/payment


This is payer-specific information that is not contained in the CPT manual but is included in this text for the benefit of exposing you to the formula commonly used to calculate charges and payment for anesthesia services. Generally, such calculation is accomplished by means of a computer program and is not manually calculated by coding or billing personnel. The formula commonly recognized by providers and payers is:


(base units + time units + modifying factors) × conversion factor = charge


image


One unit of time is equal to 15 minutes, but again this varies by payer. Time units are determined by dividing the total anesthesia time in minutes by 15. As such, the formula would be:


(base units + [time/15min]) + modifying factors (PS + QC) × conversion factor = charge


image



Summary


The following steps are necessary in assigning codes for anesthesia care:




Pain management


Generally, acute postoperative pain is managed by the surgeon, but when necessary, the surgeon may refer postoperative pain management (i.e., continuous epidural catheter infusion or nerve block) to an anesthesia provider. The surgeon must document the referral and the reason for the referral in the medical record. The anesthesia provider’s medical record documentation must demonstrate the medical necessity and intent of the epidural/nerve block as specifically for postoperative pain control. For example, the insertion of a continuous lumbar epidural catheter (62319) to infuse pain medication following a surgery known to be very painful postoperatively, such as a hemicolectomy or a joint replacement. As described in the “Anesthesia Care—Separately Reported Services” subsection above, there are situations where the insertion of the epidural is not separately reported but rather is considered to be included in the anesthesia care code (00100-01999).


The daily management of the epidural that is subsequent to the day of surgery is to be reported with 01996. This code is used to report daily management; therefore, it can only be reported once per day. This code is not necessarily time based.


Outside the anesthesia care setting, the anesthesiologist may be requested by the surgeon or attending physician to consult on the pain management of a patient. These settings can include but are not limited to hospital inpatient acute care units, including labor/ delivery, outpatient departments, clinics, and skilled nursing facilities. When a consult occurs and all required elements are performed and documented (such as documentation of request, consultant’s opinion and services rendered, and a report sent to the requesting physician), the anesthesia professional would use the inpatient or outpatient consultation E/M codes to report the service. Additionally, if a procedure is performed (such as nerve block or epidural injection), a surgical CPT code would be used.


An anesthesiologist may also be a specialist in the control of chronic pain and may work in pain clinics to treat patients with terminal illnesses (such as cancer), chronic pain, or injury.



Obstetrics


The codes for reporting anesthesia care in obstetric services are 01958-01969. Let’s take a closer look at the various components of these services.







Moderate (conscious) sedation


Types of sedation include minimal (anxiolysis), moderate, and deep. Moderate or conscious sedation (CS) is different than minimal sedation (anxiolysis). Deep sedation and monitored anesthesia care are reported with anesthesia section CPT codes 00100-01999 (only when provided by anesthesia personnel).


Moderate sedation provides a decreased level of consciousness that does not put the patient completely to sleep. This level of consciousness allows the patient to breathe without assistance and to respond to stimulation and verbal commands. It can be provided by either the physician performing the procedure or by another physician. The Anesthesia section CPT codes are not used to report moderate sedation. The codes used to report this type of conscious sedation (moderate) are located in the Medicine section (99143-99150).


The moderate sedation codes include:



The moderate sedation codes are only to be reported if the CPT code describing the surgical or diagnostic procedure does not include moderate sedation. Codes that include the moderate sedation are identified in the CPT manual with the use of a bullseye before the code, and all the codes that include the moderate sedation are listed in the CPT manual in Appendix G.


If the moderate sedation is provided by the same physician who is also performing the procedure, a trained observer is required to be present during the use of the conscious sedation to assist the physician in monitoring the patient. The service is reported with codes 99143-99145.


In the facility setting (i.e., hospital, ambulatory surgery center, skilled nursing facility), when moderate sedation is provided by a physician other than the physician performing the procedure, codes 99148-99150 are reported.


When anesthesia services (general, epidural, spinal, deep sedation, etc.) are required and provided by another physician or anesthesia professional in cases where the surgical/diagnostic procedure CPT code includes moderate sedation, the use of an anesthesia CPT codes is appropriate.


The conscious sedation codes are divided based on the age of the patient (under 5 or 5 and over), time (first 30 minutes and each additional 15 minutes), and whether the service is provided by the same physician performing the diagnostic or therapeutic service or by another physician.


Moderate sedation methods are much less debilitating than is the complete loss of consciousness. For example, for a colonoscopy, a physician could administer an intravenous sedation, such as meperidine (Demerol), morphine, or diazepam (Valium). The patient would be monitored closely as the medication is administered so that the appropriate level of sedation is reached. The patient would have this procedure in an outpatient setting and, without complications, would be able to go home after the procedure.



Patient-controlled analgesia


Patient-controlled analgesia (PCA) is a system that allows the patient to self-administer an analgesic drug intravenously by depressing a button on a pump that holds the drug. In this way the patient controls the amount of drug and the frequency of administration.



Anesthesia services in the hospital setting


If a hospital bills for anesthesiologist’s and/or CRNA’s services, it would bill the professional service component on a separate form (CMS1500 or 837-P). The codes assigned for the professional component of the anesthesia services would be the same whether the anesthesia staff were employed by the facility or were independent. The CMS-1450(UB-04) or 837-I would include all the charges for the OR, laboratory, supplies, drugs, recovery room, room and board, etc. The hospital bill may or may not include a line item billing for anesthesia. The charges that would be included under this charge would most likely be for drugs and anesthetic gases. Routine nonbillable supplies and anesthesia equipment charges are combined with the operating room charges. As a result, no anesthesia CPT codes are used on the facility claims. The ICD-9-CM codes that are assigned by the hospital coders for the anesthesiologist/CRNA are related to the actual surgical procedure performed.


You have already assigned surgical and diagnoses codes to cases throughout this text; therefore, no service or diagnosis codes need be assigned in this chapter. Prior to the reports are instructions that are necessary to correctly code the anesthesia services. When anesthesia is performed by an anesthesiologist, the instruction will indicate “MDA” (Medical Doctor of Anesthesiology). When anesthesia is performed by a Certified Registered Nurse Anesthetist, the instructions will indicate “CRNA.” When multiple anesthesia CPT codes apply to a single case, reference the following table to determine which code has the highest base unit. The one with the highest base unit is the correct code. Assign the Qualifying Circumstances code to the directing/supervising MDA.



From the Trenchesimage


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CASE 14-1   14-1A Operative Report, Flaps and Grafts


CASE 14-1


This anesthesia service is being provided for a 76-year-old patient who has severe hypertension that the physician is having difficulty managing at the time of this procedure. Anesthesia by: MDA and CRNA. Typically one provider could manage a case such as this and it would not require the services of both the MDA and CRNA. But for practice, consider the services of both anesthesia professionals to be necessary.



14-1A  Operative report, flaps and grafts


LOCATION: Inpatient, Hospital


PATIENT: Josh Peterson


SURGEON: Gary Sanchez, MD


PREOPERATIVE DIAGNOSIS: Open wound, left lower extremity, with exposed tibia and exposed plate


POSTOPERATIVE DIAGNOSIS: Ulcer, left lower extremity, with exposed tibia and exposed plate


PROCEDURES PERFORMED:



ANESTHESIA: General endotracheal


ESTIMATED BLOOD LOSS: 130 cc (cubic centimeter)


DRAINS: One #10 Jackson-Pratt


SURGICAL FINDINGS: There was an open wound extending from the lower third of the tibia up into the middle third of the leg with an exposed plate, but tissue loss of the lower third of the leg was evident. Dr. Almaz, Orthopedics, had previously inserted antibiotic beads.


PROCEDURE: An incision was made 2.5 cm medial to the tibial border. We developed a bilobed flap and identified the separation of the soleus muscle and the gastrocnemius medial head following incision of the deep fascia. I dissected the soleus muscle free distally as far as possible and then cut it distally at the Achilles tendon insertion, transposing it through a tunnel of the bilobed flap and covering the area of soft-tissue loss by using bolsters that were tied in place with 0 Prolene. This effectively covered the open area, and then we closed the remainder of the area with 0 Prolene, closing the donor area also with 0 Prolene. We put nitro paste along the edges where there was some skin blanching and put a #10 Jackson-Pratt drain in the distal end of the wound, bringing it out through a separate stab wound incision. A split-thickness skin graft about 2.5 × 2.5 cm was taken from the left thigh, meshed with 1:1.5 mesher, and applied to the defect area measuring 2.5 × 2.5 cm with 2-0 Prolene sutures and staples. We dressed the wound with Xeroform, Kerlix fluffs, Kerlix roll, Kling, and Sof-Rol, and then a cast was applied by the orthopedic technician. The donor site was dressed with scarlet red and an ABD (Adriamycin, bleomycin, dacarbazine) pad. The patient tolerated the procedure well and left the area in good condition.


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May 17, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Anesthesia

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