Vol. 14 •Issue 14 • Page 14
Coding Corner
Coding Anesthesia and Surgical Cases
Case Study 1: Anesthesia
Type of Anesthesia: General
Professional Providing the Service: Certified registered nurse anesthetist (CRNA)
Preoperative Diagnosis: Degenerative medial meniscal tear, right knee with chronic synovitis
Postoperative Diagnoses:
1. Degenerative posterior horn medial meniscal tear, right knee
2. Grade III chondromalacia of the medial femoral condyle
3. Nonspecific medial synovitis
4. Grade II chondromalacia of the patella
Procedure Performed: Examination of the right knee; diagnostic arthroscopy with subtotal medial meniscectomy and chondroplasty of the medial femoral condyle.
Under satisfactory endotracheal general anesthesia, the patient was placed supine on the operating table. The right leg was placed in a well-padded thigh-holding device, flexing the hip 20 degrees. A pneumatic tourniquet was applied at 300 mm Hg but not inflated. A routine 10-minute Betadine scrub followed by prep and sterile draping of the extremity was carried out. The knee was then examined and appeared stable.
Through a transpatellar tendon approach, after infiltration of the skin and subcutaneous tissue with 0.25 percent Marcaine and Epinephrine, a patellar tendon-splitting incision was made. After successive insertions of a blunt cannula and trocar, a 25-degree Wolf arthroscope was introduced into the suprapatellar pouch. A medial irrigation portal was established with satisfactory flow. An accessory anteromedial portal was then made.
The right knee was examined and appeared to be stable. The patella had some Grade II changes in the medial femoral condyle. The lateral femoral condyle, tibial plateau and meniscus were normal. The medial femoral condyle had some Grade III changes. The medial meniscus had a complex posterior horn tear. The tibia appeared to be satisfactory.
Using basket forceps and a motorized shaver, a subtotal medial meniscectomy was carried out. A generous chondroplasty and a very limited medial synovectomy of the femoral condyle were performed. The joint was thoroughly irrigated, infiltrated with Marcaine and a sterile dressing applied.
The patient tolerated the procedure well and was transferred to the recovery room in satisfactory condition with normal neurovascular status of the extremity.
ICD-9-CM Code Assignments
Preoperative Diagnosis: Degenerative medial meniscal tear, right knee with chronic synovitis
717.3 Other and unspecified derangement of medial meniscus
727.00 Synovitis and tenosynovitis, unspecified
Postoperative Diagnoses:
1. Degenerative posterior horn medial meniscal tear, right knee
717.2 Derangement of posterior horn of medial meniscus
2. Grade III chondromalacia of the medial femoral condyle
733.92 Chondromalacia
3. Nonspecific medial synovitis
727.00 Synovitis and tenosynovitis, unspecified
4. Grade II chondromalacia of the patella
717.7 Chondromalacia of patella
CPT Code Assignments
Before assigning CPT codes for anesthesia services, you must determine what type of anesthesia is being administered and by whom. Currently, Medicare requires you to assign one anesthesia code, while most other payers require the primary or principle surgical code.
For Medicare claims, the best way to assign an anesthesia code is to first assign the surgical code. In the above case, you would go to the CPT manual index and look up the term Arthroscopy under which the terms Surgical, then Knee É 29871Ð29889 are listed. Checking these code descriptors you will see that 29881 is the correct choice. Because a CRNA provided the anesthesia service without the presence of an anesthesiologist (i.e., no physician’s medical direction), you must also attach modifier QZ.
29881-QZ Arthroscopy, knee, surgical; with meniscectomy
The above surgical code also would be assigned for non-Medicare payers.
To assign the anesthesia code for Medicare claims, crosswalk the CPT surgical code to the appropriate anesthesia code. Code 29881 crosswalks to code 01382. Assign this code and attach modifier QZ.
01382-QZ Anesthesia for arthroscopic procedures of knee joint
Case Study 2: Musculoskeletal System
Preoperative Diagnosis: Retrognathia
Postoperative Diagnosis: Retrognathia
Procedure Performed: Sliding advancement genioplasty
Anesthesia: General endotracheal
Indications for Procedure: Twenty-one year old female with retrognathia who desires advancement genioplasty.
Operative Findings: A 4 mm segment of the genioid tubercle was advanced 5 mm anteriorly and secured with two screws. The lateral extent extended approximately 2 cm posteriorly bilaterally over the midline.
Operative Technique: The patient was taken to the operating room and placed on the operating table in a supine position. General nasotracheal anesthesia was obtained. She was draped in the usual sterile fashion. Her face was prepped with Zephiran. The mental region was injected with 1 percent Lidocaine with 1:100,000 Epinephrine.
The lower lip was retracted, and approximately a 3 cm incision was made along the mucosa of the lower lip. An incision was carried out with scissors through the mentalis muscle. After going through the mentalis muscle, the dissection was carried down to the periosteum, which was elevated inferiorly down to the inferior extent of the mandible. Dissection was carried bluntly laterally on both sides, and mental nerves were preserved.
The mandible was then retracted anteriorly, and the inferior aspect was marked with a pencil. 4 mm was marked out on both sides and the extent of the 4 mm bone advancement was approximately 2 cm on each side. An oscillating saw was then used to enter this through each bony cortex. Separated with an osteotome, it was then advanced approximately 5 mm. Two holes were drilled obliquely through the advancement tubercle into the superior aspect of the osteotome site and these were secured with two screws.
After this the mentalis muscle was closed with interrupted 4-0 Chromic stitches. The mucosa was then closed likewise with a running locking 4-0 Chromic stitch. A pressure dressing was applied to the chin. The patient tolerated the procedure well.
ICD-9-CM Code Assignments
Preoperative Diagnosis: Retrognathia
524.10 Unspecified anomaly of relationship of jaw to cranial base
Postoperative Diagnoses: Retrognathia
524.10 Unspecified anomaly of relationship of jaw to cranial base
CPT Code Assignments
To advance the mandible to a better position, an osteotomy of the mandible was performed. It was slid forward approximately 2 cm and secured with screws. Only one section of the bone was cut and moved forward.
In the CPT manual index, first refer to the term Genioplasty, then Osteotomy. The code range 21121—21123 is listed. After checking the descriptors of these codes in the surgical section, you will see that code 21121 is the correct code for both the facility and the professional assignments.
Facility Code Assignment
21121 Genioplasty; sliding osteotomy, single piece
Professional Code Assignment
21121 Genioplasty; sliding osteotomy, single piece n
Peggy Hapner is health information management consulting division manager at Medical Learning Inc. (MedLearn®), St. Paul, MN.
