CPT: Anesthesia and Surgery Codes PART THREE INTRODUCTION TO CPT Chapter 8 CPT: Anesthesia and Surgery Codes McGraw-Hill/Irwin Copyright © 2009 by The McGraw-Hill Companies, Inc. All rights reserved.

LEARNING OUTCOMES Define the concept of a complete anesthesia service. 8-2 LEARNING OUTCOMES After studying this chapter, you should be able to: Define the concept of a complete anesthesia service. Identify documentation necessary to code anesthesia services. Calculate anesthesia time units and fees based on prescribed formulas. Assign CPT anesthesia codes with appropriate HCPCS modifiers and physical status modifiers based on anesthesia procedural statements. Describe the organization, guidelines, and key modifiers for the Surgery section in CPT. List the components of a surgical package. Distinguish between the CPT and Medicare definitions of a surgical package. Describe the types of situations in which separate procedure codes are correctly reported. Select appropriate surgical modifiers for physician use and facility (hospital outpatient) use. Assign CPT surgical codes with appropriate modifiers based on surgery procedural statements.

KEY TERMS American Society of Anesthesiologists (ASA) Analgesic 8-3 KEY TERMS American Society of Anesthesiologists (ASA) Analgesic Anesthesia Anesthesia modifiers Anesthesiologist Anesthetist Bundled Closed procedure Conscious sedation (CS) Correct Coding Initiative (CCI) CCI column 1/column 2 code Pair edit CCI modifier indicators CCI mutually exclusive code (MEC) edits Diagnostic procedure Edits

KEY TERMS Endoscope General anesthesia Global period 8-4 KEY TERMS Endoscope General anesthesia Global period Global surgery days Incidental procedure Local anesthesia Medically unlikely edits (MUEs) Monitored anesthesia care (MAC) Open procedure Outpatient code editor (OCE) Physical status modifiers Qualifying circumstances Regional anesthesia Relative Value Guide Therapeutic procedure Time (tm) units Unbundling

ANESTHESIA BACKGROUND 8-5 ANESTHESIA BACKGROUND The administration of anesthesia causes the loss of the ability to feel pain. Anesthesiology is essentially the practice of medicine dealing with: Management of procedures for rendering a patient insensible to pain during procedures The evaluation and management of life functions under the stress of anesthetic and surgical manipulations The clinical management of a patient unconscious from any cause The evaluation and management of problems with pain relief The management of problems in cardiac and respiratory resuscitation The application of specific methods of respiratory therapy The clinical management of various fluids, electrolytes, and metabolic disturbances

ANESTHESIA PROVIDERS Anesthesiologist Nurse anesthetist (CRNA) 8-6 ANESTHESIA PROVIDERS Anesthesiologist Physician specialized in providing anesthesia and pain management Nurse anesthetist (CRNA) Critical care nurses who have obtained additional training in providing anesthesia

TYPES OF ANESTHESIA General Regional Peripheral Nerve Block Local 8-7 TYPES OF ANESTHESIA General Patient is rendered unconscious Steps involved are: preparation, induction, maintenance, emergence, recovery Regional Numbs a part of the body without inducing unconscious 3 Types: Spinal, Epidural, Intravenous Regional Block Peripheral Nerve Block Injecting an anesthetic solution around a nerve Local Affects a small, specific area by injection, topical or spray Monitored Anesthesia Care (MAC) The administration of sedatives, hypnotics, analgesics and anesthetic drugs

ANESTHESIA CODING Codes are located in the Anesthesia Section of CPT 8-8 ANESTHESIA CODING Codes are located in the Anesthesia Section of CPT Also listed in the American Society of Anesthesiologists (ASA) Relative Value Guide Codes are grouped anatomically by body area Anesthesia section has 19 subsections Head 00100-00222 Knee and Popliteal Area 01320 – 01444 Neck 00300-00352 Lower Leg 01462 – 01522 Thorax 00400- 00474 Shoulder and Axilla 01610 – 01682 Intrathoracic 00500 – 00580 Upper Arm and Elbow 01710 – 01782 Spine 00600 – 00670 Forearm, Wrist & Hand 01810 – 01860 Upper Abdomen 00700 – 00797 Radiological Procedures 01905 – 01933 Lower Abdomen 00800 – 00882 Burn/Excisions 01951 – 01953 Peripeum 00902 – 00952 Obstetric 01958 – 01969 Pelvis 01112 – 01190 Other Procedures 01990 - 01999 Upper Leg 01200 – 01274

ANESTHESIA SERVICES PACKAGE 8-9 ANESTHESIA SERVICES PACKAGE Anesthesia services have one code that pays for: General, regional, local anesthesia Interpretation of lab values Placement of IVs for fluid/medication administration Arterial line insertion for blood pressure monitoring The usual preoperative and postoperative visits The administration of fluids and/or blood The usual monitoring services Temperature, blood pressure, oximetry, ECG, capnography and mass spectrometry

SERVICES NOT INCLUDED IN ANESTHESIA 8-10 SERVICES NOT INCLUDED IN ANESTHESIA Can be billed separately with modifier -59 Insertion of Swan-Ganz catheter Emergency Intubation Central venous pressure line Unusual forms of monitoring such as placement of central venous lines Pain management injections or placement of epidural for postoperative pain management Critical care visits Arterial catheter Transesophageal echocardiography

OBSTETRICAL ANESTHESIA 8-11 OBSTETRICAL ANESTHESIA Two questions the coder should ask before assigning labor and delivery anesthesia codes Did the physician provide anesthesia for labor or only for delivery? Was the delivery vaginal or cesarean? Vaginal delivery codes are either 01960 or 01967 Cesarean delivery code is 01961

8-12 ANESTHESIA MODIFIERS All anesthesia codes are reported using the five-digit CPT Anesthesia section code plus the appropriate anesthesia modifier Three types of anesthesia modifiers Physical status modifiers CPT professional service modifiers HCPCS Level II modifiers

PHYSICAL STATUS MODIFIERS 8-13 PHYSICAL STATUS MODIFIERS -P1 Normal health patient -P2 Patient with mild systemic disease -P3 Patient with severe systemic disease -P4 Patient with severe systemic disease that is a constant threat to life -P5 Moribund patient who is not expected to survive without surgery -P6 Declared brain-dead patient whose organs are being removed for donation

CPT MODIFIERS -22 -23 -32 -50 -51 -52 -53 -59 -74 8-14 CPT MODIFIERS -22 Unusual (increased) procedural service -23 Unusual anesthesia -32 Mandated service -50 Bilateral procedure -51 Multiple procedures -52 Reduced services -53 Discontinued procedure -59 Distinct procedural service -74 Discontinued outpatient hospital/ambulatory surgery center procedure after the administration of anesthesia

HCPCS LEVEL II MODIFIERS 8-15 HCPCS LEVEL II MODIFIERS -AA Anesthesia personally performed by anesthesiologist -AD Medically directed more than four procedures or CRNA -QB Physician providing anesthesia in a rural health professional shortage area (HPSA) -QK Medically directed, two, three & four concurrent procedures -QS Monitored anesthesia care (MAC) -QU Physician providing anesthesia in urban HPSA

HCPCS LEVEL II MODIFIERS 8-16 HCPCS LEVEL II MODIFIERS -QY Medically directed CRNA – two to four CRNAs per one physician -QX CRNA service medically directed by a physician – one CRNA to one physician -QZ CRNA not medically directed by a physician G8 MAC for deep, complex, or complicated procedure G9 MAC for at risk Medicare patients with history of severe cardiopulmonary condition

QUALIFYING CIRCUMSTANCES 8-17 QUALIFYING CIRCUMSTANCES Are used for difficult situations under which anesthesia is administered Are add-on codes (+), so they are listed along with the appropriate anesthesia code and never used alone If more than one qualifying circumstance code applies, more than one should be assigned Four Qualifying Circumstances Codes 99100 -- extreme age, under 1 year or over 70 years 99116 – utilization of total body hypothermia 99135 – utilization of controlled hypothermia 99140 – emergency condition

ASSIGNING ANESTHESIA CODES 8-18 ASSIGNING ANESTHESIA CODES 1. Refer to the main term in the index 2. Look for the anatomical site of the procedure performed 3. Locate the code in the Anesthesia section of CPT 4. Read and apply any notes that apply 5. Determine the payer—Medicare or non-Medicare 6. For Medicare, determine who provided the anesthesia (CRNA or MD), and assign appropriate modifier 7. Assign the applicable physical status modifiers (non-Medicare) 8. Determine the type of anesthesia that was administered 9. Assign codes for any qualifying circumstances 10. Assign any other applicable modifier

8-19 ANESTHESIA TIME Begins when the anesthesiologist begins to prepare the patient for the induction of anesthesia The anesthesia staff must continuously be present in order to calculate the time Anesthesia ends when the anesthesiologist is no longer in personal attendance Generally, anesthesia is calculated in 15 minute intervals.

ANESTHESIA CODING & BILLING RESOURCES 8-20 ANESTHESIA CODING & BILLING RESOURCES The American Society of Anesthesiologists website www.asahq.org The American Society of Anesthesiologists book: The Relative Value Guide Medicare has a anesthesia webpage www.cms.gov/center/anest.asph Commerical sources Decision Health’s Anesthesia & Pain Coder’s Pink Sheet and Anesthesia Answer Book The American Professional Academy of Coders (AAPC) Coding Edge The American Health Information Management Association's (AHIMA) Journal of the American Health Information Management Association

SURGERY CODING OVERVIEW 8-21 SURGERY CODING OVERVIEW The Surgery section is the largest section in CPT There are 16 subsections based on organ systems All surgery codes will begin with a 1, 2, 3, 4, 5 or 6 and are related to the subsection they are located in Most surgical subsections are divided by anatomical sites or organs within each body system Each anatomical site is then divided further by surgical method

SURGERY SUBSECTIONS Integumentary System 10021 - 19499 8-22 SURGERY SUBSECTIONS Integumentary System 10021 - 19499 Musculoskeletal System 20000 - 29999 Respiratory System 30000 - 32999 Cardiovascular System 33010 - 39599 Hemic and Lymphatic Systems 38100 - 37799 Mediastinum and Diaphragm 39000 - 39599 Digestive System 40490 - 49999 Urinary System 50010 - 53899 Male Genital System 54000 - 53899 Intersex Surgery 55700 - 55899 Female Genital System 56405 - 58999 Maternity Care and Delivery 59000 - 59899 Endocrine System 60000 - 60699 Nervous System 61000 - 64999 Eye and Ocular Adnexa 65091 - 68899 Auditory System 69000 - 69990

SURGICAL METHODS WITHIN A SUBSECTION 8-23 SURGICAL METHODS WITHIN A SUBSECTION Incision and Drainage Biopsy Excision Introduction or Removal Repair Destruction Endoscopy/Laparoscopy Other Procedures

8-24 SURGERY GUIDELINES Be careful when assigning the add-on code for a microscope The term complicated appears in some code descriptions Some codes specify whether they are for one or both of an anatomical pair Add-on codes are never coded independently

SURGICAL PACKAGE AND THE GLOBAL PERIOD 8-25 SURGICAL PACKAGE AND THE GLOBAL PERIOD Time, effort and services for the surgical procedures are coded with a single package code Package includes: Local infiltration of anesthesia, the E/M visits either on the date of surgery or day before, immediate postoperative care, writing orders, evaluating the patient in the recovery room and typical, uncomplicated follow-up Global period is a defined time for routine preoperative and postoperative surgical care No days for simple procedures No days preoperative and ten days postoperative for minor surgery One day preoperative and ninety days postoperative for major surgery

BUNDLING Surgical packages are bundled 8-26 BUNDLING Surgical packages are bundled Bundled means that each package code contains all the related services Unbundling, or taking apart and reporting the services separately is a coding error and fraud

SERVICES NOT INCLUDED IN THE GLOBAL SURGERY PACKAGE 8-27 SERVICES NOT INCLUDED IN THE GLOBAL SURGERY PACKAGE The initial consultation or evaluation of the problem by the surgeon to determine the need for surgery. A modifier -57 would apply in this circumstance Diagnostic tests and procedures Distinctly unrelated surgical procedures during the postoperative period. Treatment for postoperative complication that requires a return trip to the operating room A more extensive procedure that is required when a less extensive procedure fails For certain services performed in the physician office, a surgical tray, drugs, splints, or casting. Immunosuppressive therapy for organ transplants

8-28 SEPARATE PROCEDURE Located in the CPT index in parentheses after code description Not coded when: It is an integral part of another procedure And it is more of an incidental procedure than the comprehensive procedure

SURGERY SECTION GUIDELINES 8-29 SURGERY SECTION GUIDELINES The section guidelines in the CPT will list applicable modifiers to the Surgery section New, unusual, unlisted codes or codes with modifiers -21, -22, -23, -59, -66, -80, -81, 99 need special documentation to support the medical necessity. All surgery subsections are listed in the Surgery section guidelines Unlisted procedures are used for services with no assignable CPT code

TWO TYPES OF SURGICAL PROCEDURES 8-30 TWO TYPES OF SURGICAL PROCEDURES Diagnostic Are performed to confirm a physician’s working diagnosis or help determine a treatment course Endoscopy, bronchoscopy, biopsy, angiography Therapeutic Involve treating/correcting a confirmed disease/injury Excision, repair, transplants, reconstruction

SURGERY MODIFIERS Used to report various situations, such as: 8-31 SURGERY MODIFIERS Used to report various situations, such as: A procedure was performed bilaterally More than one procedure was performed at the same time Assistant surgeon participation An increased/decreased service or procedure Performance of part of a service Unusual events during a procedure or service A specific anatomical located A service that has two parts Professional and technical components More than one procedure or service on the same day

SURGERY MODIFIERS -E1 – upper left, eyelid -E2 – lower left, eyelid 8-32 SURGERY MODIFIERS -E1 – upper left, eyelid -E2 – lower left, eyelid -E3 – upper right, eyelid -E4 – lower right, eyelid -F1 – left hand, second digit -F2 – left hand, third digit -F3 – left hand, fourth digit -F4 – left hand, fifth digit -F5 – right hand, thumb -F6 – right hand, second digit -F7 – right hand, third digit -F8 – right hand fourth digit -F9 – right hand fifth digit -FA – left hand, thumb -TC – technical component

SURGERY MODIFIERS -LC – left circumflex coronary artery 8-33 SURGERY MODIFIERS -LC – left circumflex coronary artery -LD – left anterior descending coronary artery -RC – right coronary artery -RT – right side -T1 – left foot, second digit -T2 – left foot, third digit -T3 – left foot, fourth digit -T4 – left foot, fifth digit -T6 – right foot, great toe -T7 – right foot, second digit -T8 – right foot, third digit -T9 – right foot, fifth digit -TA – left foot, great toe -LT – left side

DESCRIPTION OF MODIFIERS 8-34 DESCRIPTION OF MODIFIERS -22 – unusual (increased) procedural services -27 – multiple outpatient hospital E/M encounters on the same date -32 – mandated services -47 – anesthesia by surgeon -50 – bilateral procedure -51 – multiple procedures -52 – reduced services -53 – discounted procedure -54 – surgical care only -55 – postoperative management only -56 – preoperative management only -57 – decision for surgery -58 – staged or related procedure or service by the same physician during the postop period -59 – distinct procedural service -62 – two surgeons

DESCRIPTION OF MODIFIERS 8-35 DESCRIPTION OF MODIFIERS -63 – procedure performed on infants less than 4 kg -66 – surgical team -73 - discontinued out-patient hospital/ambulatory surgery center procedure prior to the administration of anesthesia 74 - discontinued out-patient hospital/ambulatory surgery center procedure after administration of anesthesia -76 – repeat procedure by same physician -77 – repeat procedure by another physician -78 – return to the operating room for a related procedure during the postoperative period -79 – unrelated procedure or service by the same physician during the postoperative period -80 – assistant surgeon -81 – minimum assistant surgeon -82 -- assistant surgeon (when qualified resident surgeon not available) -99 – multiple modifiers

STEPS IN ASSIGNING SURGERY MODIFIERS 8-36 STEPS IN ASSIGNING SURGERY MODIFIERS 1. Read all the documentation. 2. Determine whose service is being coded. 3. Make sure the code description for the CPT code does not already include identifiers. 4. If the CPT code description includes several body parts in one code description do not assign an anatomic modifier. 5. If a procedure is performed separately from the complex procedure, a -59 may be applicable. 6. Determine the time frame within which a service was performed and consider using -24, -58, -76, -77, -78, -79. 7. If an assistant surgeon or other provider performed a portion of the procedure consider using -80, -62, -66, -80, -81, -82. 8. For Medicare patients refer to HCPCS as well as CPT. 9. Sequence modifiers

INTEGUMENTARY SUBSECTION 8-37 INTEGUMENTARY SUBSECTION Contains codes for procedures performed on the skin and underlying tissues. Common headings include: Incision and drainage Excision – debridement Paring or cutting Biopsy Removal of skin tags Shaving of epidermal or dermal lesions Excision – benign lesions and malignant lesions Repair – simple, intermediate, and complex Adjacent tissue transfer or rearrangement Skin replacement surgery and skin substitutes Flaps Pressure ulcers Burns Destruction, benign, premalignant or malignant lesions Mohs micrographic surgery Breast repair and/or reconstruction

MUSCULOSKELETAL SUBSECTION 8-38 MUSCULOSKELETAL SUBSECTION Largest subsection in the Surgery section Procedures are performed on bones, tendons, soft tissues and muscles Common headings: Incision Excision Introduction or removal Repair Revision and/or reconstruction Fracture and/or dislocation Arthrodesis Amputation Other procedures

RESPIRATORY SUBSECTION 8-39 RESPIRATORY SUBSECTION Procedures on the sinuses, nose, larynx, trachea, bronchi, lungs and pleura. Many of the procedures are performed via endoscope Common headings: Endoscopy, laryngoscopy or bronchoscopy Excision of nasal polyps or turbinates Rhinoplasty Septoplasty Cauterization Anterior/posterior nasal packing Insertion of nasal stents, balloons, tampons and catheters

CARDIOVASCULAR SUBSECTION 8-40 CARDIOVASCULAR SUBSECTION Procedures on the heart, veins, and arteries Codes from three different sections of CPT may be assigned: Cardiovascular Contains surgical codes (33010 – 37799) Medicine Contains codes for cardiac-related nonsurgical services (92950 – 93799) Radiology Contains codes to be assigned when imaging is used to perform a service on the heart (75552 – 75790)

CARDIOVASCULAR SUBSECTION 8-41 CARDIOVASCULAR SUBSECTION Common Headings: Pacemakers or Defibrillators Arteries and Veins Coronary Artery Bypass Graft (CABG) Angioplasty Venous Access Device Catheter Placement Implantable Venous Access Device

HEMIC AND LYMPHATIC SYSTEMS SUBSECTION 8-42 HEMIC AND LYMPHATIC SYSTEMS SUBSECTION Procedures performed on Hemic (blood-producing) and Lymphatic Systems, including spleen, bone marrow, lymph nodes, mediastinum and diaphragm Common Headings: Splenectomy Bone marrow or stem cell Lymph node biopsy Lymphadenectomy

8-43 DIGESTIVE SUBSECTION Procedures for the digestive flow in the body beginning with the lips and mouth and ending with the anus. Organs used to aid digestion: pancreas, appendix, gallbladder and liver Common Headings: Tonsillectomy and Adenoidectomy Hernia repairs Appendectomy Cholecystectomy Esophagoscopy and Esophagogastroduodenoscopy(EGD) Bariatric Surgery Colonoscopy Hemorrhoidectomy

8-44 URINARY SUBSECTION Procedures on the kidneys, ureters, bladder, and urethra Urinary system codes are organized by those body parts and then by procedure: Incision Excision Introduction Repair Laparoscopy Cystourethroscopy Prostate Procedures

MALE GENITAL; INTERSEX SUBSECTION 8-45 MALE GENITAL; INTERSEX SUBSECTION Procedures on the penis, testicles, and prostate Common Headings: Orchiopexy Orchiectomy Circumcision Destruction of Lesions Vasectomy Vasovasorrhaphy

FEMALE GENITAL AND MATERNITY AND DELIVERY SUBSECTION 8-46 FEMALE GENITAL AND MATERNITY AND DELIVERY SUBSECTION Procedures on the uterus, ovaries, fallopian tubes, vagina, vulva, clitoris, vestibule and vaginal orifice Common Headings: Laparoscopy and Hysteroscopy Sterilization Lesion removal Maternity Care includes routine antepartum care, delivery and postpartum care called OB package

ENDOCRINE AND NERVOUS SUBSECTION 8-47 ENDOCRINE AND NERVOUS SUBSECTION Procedures on skull, meninges, brain, spinal cord, extracranial nerves, peripheral nerves and autonomic nervous system Many of the codes in this section require the use of a microscope. Assign 69990 when documented. Common Headings: Spinal injections and pain management Nerve blocks Transcutaneous Electrical Nerve Stimulator (TENS) Blood Patch Lumbar Puncture Chemodenervation Neurolysis Nerve Decompression

EYE, OCULAR ADNEXA AND AUDITORY SUBSECTION 8-48 EYE, OCULAR ADNEXA AND AUDITORY SUBSECTION Procedures on the eyeball, anterior/posterior segment, ocular adnexa, conjunctiva, outer/inner ear The codes are arranged by anatomical site and then by the procedure: Incision Excision Repair Other procedures Other Headings: Foreign body removal Cataract removal Lesion removal Glaucoma Surgery LASIK Tympanoplasty Ventilation Tube Insertion