Chapter 16

Practical Application Tips

General Hints for Chapter 16

1. You are coding for the anesthesiologist and/or CRNA for each case. Codes for
anesthesia services are typically found in the Anesthesia Section of CPT®. There are
additional billable items that come from other CPT® sections and are discussed in the
textbook.
2. For each of these cases, there is an anesthesia time increment answer. It is the last
answer in each case and will need to be converted into total minutes.
3. Anesthesia modifiers can only be used with CPT® anesthesia codes
4. The provider anesthesia modifier precedes the modifier for MAC. The physical status
modifier is always placed last.

Case 1 – The anesthesiologist personally performed the anesthesia for this procedure. The
documented procedure is a radical retropubic prostatectomy. The prostate is considered
extraperitoneal in the lower abdomen. In the CPT Index locate
Anesthesia/Prostatectomy/Radical. The documented diagnosis is prostate cancer. In the
ICD-10-CM Table of Neoplasms locate Neoplasm, neoplastic/prostate/Malignant Primary
column.

Case 2 – The anesthesiologist personally performed the anesthesia for this procedure. The
documented procedure indicates many procedures were performed on the lumbar spine,
however only one anesthesia code is reported for the most complex procedure. The
laminectomy is the most complex procedure performed. Look in the CPT Index for
Anesthesia/Spine and Spinal Cord/Lumbar for the code range. In the Alphabetic Index
locate Stenosis/spinal/lumbar region.

Case 3 – The anesthesiologist personally performed monitored anesthesia for a

bronchoscopy. In the CPT Index locate Anesthesia/Bronchoscopy. The carcinoma is of the
right lower lobe of the lung. In the ICD-10-CM Table of Neoplasms locate Neoplasm,
neoplastic//lung/lower lobe/Malignant Primary.

Case 4 – The anesthesiologist personally performed the monitored anesthesia for sternal
wound exploration and wound vac placement. The procedure was to evacuate a hematoma
in the upper abdominal wall wound. In the CPT Index look for
Anesthesia/Abdomen/Abdominal Wall for the code range. The diagnosis is a postoperative
hematoma. In the Alphabetic Index locate Hematoma/postoperative and you’re directed to
see Complication, postprocedural. Locate Complication/postprocedural/hematoma (of)/skin
and subcutaneous tissue/following a procedure on other organ.

Case 5 – You are reporting for a non-medically directed CRNA. The procedures are a
cystoscopy and the exchange of ureters. This is found in the urinary tract in the lower
abdomen. Look in the Index for Anesthesia/urinary tract. The diagnosis is a postoperative
stricture of the ureter. In the Alphabetic Index, locate Stricture/ureter (postoperative).

Case 6 – You are reporting CPT® and ICD-10-CM codes for the anesthesiologist and CRNA.
The anesthesiologist is directing two CRNAs which is important in modifier selection. A
Baker’s cyst is located behind the knee. Look in the CPT Index for Anesthesia/Knee for the
code range. ** The excision makes this an open procedure. The documented diagnosis is
Baker’s cyst. Look in the ICD-10-CM Alphabetic Index for Cyst/Baker’s.

Case 7 – You are reporting CPT® and ICD-10-CM codes for the anesthesiologist and CRNA.
The anesthesiologist is directing one CRNA. The procedure is a partial nephrectomy. In the
CPT Index locate Anesthesia/Nephrectomy. The CRNA performed a percutaneous insertion
of an arterial line (catheter). For the Arterial Line locate Cannulation/Arterial. The diagnosis
is renal mass. In the Alphabetic Index locate Mass/kidney.

Case 8 – You are reporting CPT® and ICD-10-CM codes for the anesthesiologist and CRNA.
Two CPT® codes are reported for the Anesthesiologist directing three cases. To report the
circumcision, look in the CPT Index for Anesthesia/Genitalia/Male. A Qualifying
Circumstance is coded for a patient of extreme age. The CRNA does not code for extreme
age. Pay close attention to the order of the anesthesia modifiers. Report one ICD-10-CM
code for congenital phimosis.

Case 9 – You are reporting for a non-medically directed CRNA. Two CPT® codes are
reported. The first code is anesthesia for the knee arthroplasty. In the CPT Index locate
Anesthesia/Arthroplasty/Knee. The second code is the continuous femoral nerve catheter.
Look in the CPT Index for Femoral Nerve/Injection/Anesthetic. The reason for this procedure
is post-operative pain management using a catheter to administer pain medical after the
surgery. A modifier is appended to indicate this is a distinct separate procedure and not
used for anesthesia for the procedure. The documented diagnosis is localized, primary
osteoarthrosis of the left knee. In the ICD-10-CM Alphabetic Index locate
Osteoarthritis/primary/knee. You will need a second diagnosis code to provide medical
necessity for the continuous femoral nerve catheter for postoperative pain management.
There are ICD-10-CM guidelines on how to report postoperative pain. Refer to guideline
I.C.6.b.3. for direction.

Case 10 – You are reporting CPT® and ICD-10-CM codes for the anesthesiologist and CRNA.
The anesthesiologist is directing two CRNAs which is important in modifier selection. Two
CPT codes are reported for the Anesthesiologist.
1. The first code is the anesthesia for the CABG. The patient was placed on
cardiopulmonary bypass indicating the use of a “pump oxygenator”. The description
of a pump oxygenator is in your textbook under Anesthesia Coding Terminology. In
CPT Index locate Anesthesia/Heart/Coronary Artery Bypass Grafting for the code
range. A Qualifying Circumstance code for a patient of extreme age is the second
code. Qualifying Circumstance codes are in the CPT® Anesthesia Guidelines.
2. The CRNA reports the same anesthesia code as the anesthesiologist, but will also be
billing for three additional procedures in this order– insertion of the Central Venous
catheter, Swan-Ganz catheter, and A-line (or Arterial Line). A modifier is needed on
the central venous catheter procedure code, to show that it is not bundled with the
Swan-Ganz catheter. In the CPT Index locate Central Venous Catheter
Placement/Insertion/Central non-tunneled. Code selection is based on the patient’s
age. For the Swan-Ganz locate Swan-Ganz Catheter/Insertion. For the A-line
insertion locate Arterial Catheterization and you ‘re directed to See Cannulation,
Arterial.
3. The documented diagnosis is coronary artery disease of a native artery. Use the
same diagnosis for both the anesthesiologist and the CRNA. Look in the Alphabetic
Index for Disease, diseased/artery/coronary.
 Chapter 16 FAQs

How is anesthesia time reported?

Report anesthesia time in minutes. You always start anesthesia time when the
anesthesiologist begins to prepare the patient for the induction of anesthesia. Anesthesia
time ends when the anesthesiologist is no longer in personal attendance. This means, the
patient is out of the O.R. and in recovery and is turned over to the recovery room nurses.

What are anesthesia modifiers?

There are many types of modifiers for anesthesia. Anesthesia modifiers identify the
anesthesia personnel providing the anesthesia service. These modifiers are used only with
CPT® anesthesia codes (00100-01999). Do not place anesthesia modifiers on surgical CPT®
codes.

If an anesthesiologist is providing anesthesia services, the service is identified with modifier

AA, such as 01230-AA. If a CRNA is providing anesthesia services, the service is identified
with modifier QZ, such as 01230-QZ.
All the anesthesia modifiers are in the HCPCS Level II codebook.

How are anesthesia modifiers sequenced?

The order of these modifiers is: anesthesia provider first, followed by monitored anesthesia
care, if provided, followed by physical status modifier (example, 00562-AA-QS-P4)

Can you show me an example of how to report an anesthesiologist directing CRNAs while
providing anesthesia care concurrently?
An anesthesiologist may direct up to four CRNAs providing anesthesia care concurrently.
When an anesthesiologist directs CRNAs, both the anesthesiologist and the CRNA report
their services. For example, Anesthesiologist Dr. A, may be directing three CRNAs.

CRNA A - 01230
CRNA B - 01860
CRNA C - 01462

The first case for CRNA A would be coded:

Anesthesiologist: 01230-QK
CRNA: 01230-QX

Second case for CRNA B would be coded:

Anesthesiologist: 01860-QK
CRNA: 01860-QX

Fourth case for CRNA C would be coded:

Anesthesiologist: 01462-QK
CRNA: 01462-QX

Now, let's say that the anesthesiologist is supervising 5 cases. Then each case for the
anesthesiologist is reported with modifier AD, and each case for the CRNA is reported with
QX.
If the anesthesiologist is directing only one case 01230, report:
Anesthesiologist: 01230-QY
CRNA: 01230-QX