Step by Step Lesson 12-1 Anesthesia

Buck’s Step By Step Chapter 12: Anesthesia Chapter Introduction and Learning Objectives  Chapter Introduction 1. Most anesthesia is administered in the support of a patient during surgery: a. There are many other types and uses of anesthesia 2. Can calculate anesthesia payments based on: a. The widely used anesthesia formula b. Convert the formula into the reimbursement amount 3. Some of the CPT code descriptions for physician services include physician extender services a. Physician extenders are: i. Nurse practitioners ii. Physician assistants iii. Nurse anesthetists iv. Etc b. Provide medical services typically performed by a physician c. Refer to the official CPT code descriptions and guidelines to determine codes that are appropriate to report services provided by non-physician practitioners  Chapter Learning Objectives  Voices of Experience  Using the Chapter Outline  Lesson 12-1: Anesthesia  Lesson Introduction  Lesson 12-1 Learning Objectives  Anesthesia 1. Anesthesia is used to/for the following: (according to the American Society of Anesthesiologists): a. The management of procedures for rendering a patient insensible to pain and emotional stress during procedures: i. Surgical ii. Obstetrical iii. Other diagnostic procedures iv. Other therapeutic procedures b. The evaluation and management of essential physiologic functions under the stress of anesthetic and surgical manipulations c. The clinical management of the patient unconscious from whatever cause d. The evaluation and management of acute or chronic pain e. The management of problems in cardiac and respiratory resuscitation f. The application of specific methods of respiratory therapy g. The clinical management of various disturbances, such as: i. Fluid ii. Electrolyte iii. Metabolic 2. * The definitions above were excerpted from 2022 Relative Value Guide of the American Society of Anesthesiologists *  Section Format 1. The Anesthesia section is formatted by anatomical divisions a. The codes are first divided by anatomic site b. Then by type of procedure 2. For example:

a. The anesthesia service of the administration of a lumbar, sacral or caudal block: i. Would be coded with a code from the surgery section (62322 or 62326) for the injection ii. Often used in conjunction with a general anesthesia code when the block/spinal is the mode of anesthesia for a procedure such as: 1. Below knee amputation (01482) a. Anesthesia for open procedures on bones of lower leg, ankle, and foot 2. Radical resection a. Including below knee amputation iii. This technique is also called regional anesthesia iv. The code 62322 or 62326 would NOT be coded 1. Only the anesthesia code is billed as the spinal is the mode of anesthesia 3. Slideshow: a. A common regional anesthetic is a Caudle block i. Used in pediatric patients ii. Used in conjunction with General Anesthesia b. Landmarks are located and marked on the skin to provide a map for injection c. The area is cleaned d. Then the needle is inserted 4. The lumbar, sacral or caudal block would be billed separately if: a. A general anesthetic is also administered for postoperative pain management b. Whenever postoperative pain management blocks are given, before or after anesthesia: i. The CPT code for the clock is reported with Modifier -59 1. To show that it is separate c. In the above example: i. If a general anesthetic was administered for the procedure and a continuous epidural was performed for postoperative pain management code: 1. 01482-AA a. AA for anesthesiologist 2. 62326-59  Anesthesia Formula 1. Anesthesia Formula : a. Reimbursement for anesthesia services is based on this b. Formula contains the following components: i. B for Base Unit Value ii. T for Time Units iii. M for Modifying Units 2. Base Units (B) a. One component of the Anesthesia Formula b. The base unit value is published in the RVG (Relative Value Guide) by the American Society of Anesthesiologists i. The guide establishes base unit values for anesthesia services based on:

2. The full description for these codes are located in these sections of the CPT manual: a. Anesthesia Guidelines b. Medicine Section iv. Anesthesia Modifier: 1. Does not affect the total units billed 2. Indicates the type of provider administering the anesthesia 3. Examples: a. -AA for the anesthesiologist personally performing the anesthesia service b. QZ for a CRNA without medical direction by a physician i. Often anesthesia services are performed without medical direction ii. Up to 4 CRNAs may be providing anesthesia at one time 1. (Concurrently) iii. While one anesthesiologist is providing the medical direction of the 4 CRNAs 4. The Anesthesia modifiers always directly follow the CPT anesthesia code 5. The Physical Status modifier is placed last  Self-Comprehension Questions 1. Which of the following is not a unit of the Anesthesia Formula: a. Base b. Conditional c. Time d. Modifying 2. The correct units in the Anesthesia Formula are: a. Base b. Time c. Modifying d. NOT conditional  Self-Comprehension Questions 1. With which letter of the alphabet does the Physical Status Modifiers begin? a. PSM b. PS c. S d. P 2. The physical Status Modifiers begin with the letter P  Summing Up the Formula 1. Total Anesthesia Base Units a. Derived from the Base Unit Value assigned to anesthesia CPT codes i. From the RVG b. Time units i. Ex: 15 minutes = 1 unit c. Modifier Base Value Units assigned to Qualifying Circumstances i. 99100-9914 d. Physical Status i. P1-P6 2. Anesthesia Formula: a. B + T + M = Total Anesthesia Units

b. The total anesthesia units are then multiplied by the conversion factor to equal the payment for anesthesia services i. Dollar value assigned for each one unit c. Example: i. Illustrates the CMS Anesthesia Conversion Factors ii. An anesthesiologist located in Manhattan, NY would be paid $24.60 per unit 1. Conversion Factor for Manhattan, NY  Anesthesia for Multiple Surgical Procedures 1. When multiple procedures are performed during the same session: a. Choose the procedure with the highest base units b. Only one anesthesia CPT code can be billed i. The most work-intensive anesthesia code is listed ii. Example: 1. If the patient had multiple repairs to tendons of the shoulder a. 5 base units 2. Also a repair of the knee joint a. 4 base units 3. Only the procedure with the highest base units (5) would be used to calculate the payment for the procedure 4. The anesthesia code representing the most complex procedure (5) is reported a. PLUS the time units for all procedures b. AND the modifying factors are calculated c. The length of time of the total anesthesia service will account for the other procedures  Lesson 12-1 Learning Activity 1. Using the CPT Anesthesia Guidelines, heading “Time Reporting” information, complete the following: Time for anesthesia procedures may be reported as is customary in the _______ area. a. Statewide b. Local c. Municipal d. Urban 2. According to the CPT Anesthesia Guidelines, heading “Supplied Materials” information, which CPT code would be used to report drugs, materials, and tray supplies provided during an anesthesia service? a. 99070 b. 90000 c. 99990 d. 99024  Lesson 12-1 Quiz 1. Anesthesia complicated by emergency conditions: a. Code: 99140 2. Anesthesia complicated by utilization of controlled hypotension: a. Code: 99135 3. Operative Report: Preoperative Diagnosis: Right rotator cuff tear/degenerative joint disease, right

Postoperative Diagnosis: Same. Operation: Closed reduction and percutaneous pin fixation of displaced fractures of the left index and long metacarpal shafts. Anesthesia: General. Indications: The patient is a 22-year-old, right-hand dominant man who sustained left index and long metacarpal shaft fractures when stepped on while playing soccer a few days ago. He was treated with a provisional reduction and casting in the emergency department with unsatisfactory alignment. He was subsequently referred to my office and was found to have internal rotation and shortening deformities through the index and long metacarpal shaft fractures and was subsequently scheduled for closed, possible open reduction and percutaneous pin fixation or possible internal fixation of the above- mentioned fractures. Procedure: The patient was placed in the supine position on the operating table. He was administered a general anesthetic. Left proximal arm tourniquet was placed and the left upper extremity was prepped and draped in the usual sterile fashion. The arm was exsanguinated with an Esmarch bandage and the tourniquet inflated to 250mm Hg. Sterile finger traps and ropes were then applied to the left index and long fingers and 10 lb of weight was then applied over the end of the hand table. The fractures were then gently manipulated and multiple fluoroscopic views were obtained, which revealed satisfactory alignment. Attention was then turned to the index metacarpal shaft fracture, which was percutaneously pinned from its radial to ulnar aspect, with excellent purchase being obtained on both sides. X-rays were then taken, which revealed anatomic alignment. Attention was then turned to the long metacarpal shaft fracture, which was still slightly distracted and displaced. Additional manipulation was performed. A pin was initially inserted from radial to ulnar, which resulted in further distraction of the fracture. The pin was then removed and another pin was inserted from the ulnar to radial. This appeared to close the fracture gap and held the fracture in better alignment. A second pin was then placed just proximal and parallel to the original pin, with resultant satisfactory alignment. There was still slight gapping at the fracture site, but the rotation and angulation were corrected. The finger traps were removed and the fingers were flexed to a satisfactory degree. All finger tips appeared to point to the distal pole without any evidence of angulation or rotation malalignment. The pins were trimmed and bent over at 90-degree angles. The pin site was irrigated and Xeroform dressings were applied. Sterile gauze, compressed hand dressing was then applied, reinforced with a plaster cast with the hand placed in the intrinsic plus position and the PIP joint free. The patient tolerated the procedure well, estimated blood loss was 0.2 mL. The patient was sent to recovery room in satisfactory condition with instructions for strict hand elevation in a Carter arm pillow. He was given a prescription of Vicodin to be taken on an as-needed basis and was advised to call the office for a follow-up appointment in 10 to 14 days for cast change. He is advised to call the office if any problems or questions should arise prior to his scheduled appointment. b. CPT Anesthesia Code: 01820 Chapter Review  Chapter 12 Review  Chapter Review Exercises  Take A Break  Taking the Chapter Exam End of Chapter 12-1: Anesthesia Chapter 12 Self-Practice Questions Part 1 1. The anesthesia section is divided: a. Anatomically

2. P2 identifies a: a. Mild systemic disease 3. The M in the anesthesia formula means: a. Modifying 4. If two procedures are performed during the same surgical session, the anesthesia service would be reported by: a. Reporting only the base units for the most resource intensive procedure plus the total time units 5. Time for anesthesia procedures may be reported as is customary in the ________ area. a. Local 6. What modifier identifies as an anesthesia service that was performed personally by an anesthesiologist? a. -AA 7. Moderate sedation codes are located in the ________ __________ and may be reported when the physician performing the procedure administers the sedation. a. Medicine section 8. Which subsection in Anesthesia is not organized by anatomic division? a. Obstetric 9. The ______ time is when the patient can be safely turned over to a non- anesthesia provider. a. Stop 10. Qualifying Circumstances codes have this symbol beside them to indicate the code cannot be reported alone. a. + Chapter 12 Self-Practice Questions Part 2 1. A full-thickness graft of the external ear. a. 00120 2. A partial rib resection by means of thoracoplasty. a. 00472 3. A thrombectomy with a catheter of the subclavian vein by means of the neck incision. a. 00350 4. Cystolithotomy. a. 00870 5. A vertebral corpectomy of the lumbar region, not otherwise specified. a. 00630 6. An intraperitoneal procedure abdomen. a. 00790 7. A procedure on the cervical spine and cord, not otherwise specified. a. 00600 8. An open procedure of the wrist, not otherwise specified. a. 01830 9. A pneumonectomies. a. 00524 10. A procedure of the esophagus, not otherwise specified, patient age 7. a. 00320