INTRODUCTION TO CPT

PART THREE

Chapter 8

CPT: Anesthesia and Surgery

Codes

McGraw-Hill/Irwin Copyright © 2009 by The McGraw-Hill Companies, Inc. All rights reserved.

LEARNING OUTCOMESAfter studying this chapter, you should be able to:

1. Define the concept of a complete anesthesia service.2. Identify documentation necessary to code anesthesia services.3. Calculate anesthesia time units and fees based on prescribed

formulas.4. Assign CPT anesthesia codes with appropriate HCPCS modifiers

and physical status modifiers based on anesthesia procedural statements.

5. Describe the organization, guidelines, and key modifiers for the Surgery section in CPT.

6. List the components of a surgical package.7. Distinguish between the CPT and Medicare definitions of a surgical

package.8. Describe the types of situations in which separate procedure codes

are correctly reported.9. Select appropriate surgical modifiers for physician use and facility

(hospital outpatient) use.10. Assign CPT surgical codes with appropriate modifiers based on

surgery procedural statements.

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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

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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

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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

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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

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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

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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 – 01444Neck 00300-00352 Lower Leg 01462 – 01522 Thorax 00400- 00474 Shoulder and Axilla 01610 –

01682Intrathoracic 00500 – 00580 Upper Arm and Elbow 01710 – 01782Spine 00600 – 00670 Forearm, Wrist & Hand 01810 – 01860Upper Abdomen 00700 – 00797 Radiological Procedures 01905 – 01933Lower Abdomen 00800 – 00882 Burn/Excisions 01951 – 01953Peripeum 00902 – 00952 Obstetric 01958 – 01969Pelvis 01112 – 01190 Other Procedures 01990 - 01999Upper Leg 01200 – 01274

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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

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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

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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

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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

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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

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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

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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

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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

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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

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ASSIGNING ANESTHESIA CODES

1. Refer to the main term in the index2. Look for the anatomical site of the procedure performed3. Locate the code in the Anesthesia section of CPT4. Read and apply any notes that apply5. Determine the payer—Medicare or non-Medicare6. For Medicare, determine who provided the anesthesia

(CRNA or MD), and assign appropriate modifier7. Assign the applicable physical status modifiers (non-

Medicare)8. Determine the type of anesthesia that was administered9. Assign codes for any qualifying circumstances10. Assign any other applicable modifier

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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.

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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

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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

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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

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SURGICAL METHODS WITHIN A SUBSECTION

• Incision and Drainage• Biopsy• Excision• Introduction or Removal• Repair• Destruction• Endoscopy/Laparoscopy• Other Procedures

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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• -RT – right side• -LT – left side

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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

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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

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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

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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

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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

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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

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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)

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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

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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

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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

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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

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MALE GENITAL; INTERSEX SUBSECTION

• Procedures on the penis, testicles, and prostate• Common Headings:

– Orchiopexy– Orchiectomy– Circumcision– Destruction of Lesions– Vasectomy– Vasovasorrhaphy

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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

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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

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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

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