Coding Anesthesia Provided for Surgery

Coding Anesthesia Provided for Surgery

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Coding Anesthesia Provided for Surgery

Dawn Seelye, RHIA

Case Study 1

Dawn Seelye Preoperative Diagnosis: Carcinomatous meningitis

Type of Anesthesia: General endotracheal

Anesthesia Provider: Anesthesiologist

Procedure Performed: Right frontal cerebrospinal fluid (CSF) reservoir placement

Technique: After inducing adequate endotracheal anesthesia, the anesthesiologist elevated the patient’s head slightly. The hair in the right frontal region was shaved, and the head and hair were prepped with Betadine scrub solution.

The surgeon marked a standard curvilinear incision above and behind the hairline centered about 4 cm off the midline in front of the coronal suture. The surgeon infiltrated the incision with 0.5 percent lidocaine with 1:200,000 epinephrine and took the incision down to the galea. The flap was turned down subgaleally and the pericranium was incised longitudinally.

A burr hole was made with the Midas-Rex. A 15-cm straight ventricular catheter was then easily placed into the ventricle. We reached CSF at about 6 cm. The catheter was cut off at about 7 cm and connected to the Rickham reservoir with a 2-0 silk tie. A 3-0 silk was used to affix the reservoir to the pericranium, 2-0 Vicryl was used to close the galea, and 4-0 subcuticular sutures and Steri-strips were placed in the skin.

Postoperative Diagnosis: Carcinomatous meningitis

ICD-9-CM Code Assignment

198.4 Secondary malignant neoplasm of other parts of nervous


CPT Procedure Code Assignment

For Medicare Patients:

00214 Anesthesia for intracranial procedures; burr holes, including ventriculography

For Non-Medicare Patients:

61210 Burr hole(s); for implanting ventricular catheter,

reservoir, EEG electrode(s) or pressure recording device (separate procedure)

Note: Because an anesthesiologist provided the anesthesia, remember to attach modifier -AA to either code 00214 or 61210, whichever the third-party payer requires.

Case Study 2

Preoperative Diagnosis: Nasal fracture

Type of Anesthesia: General

Procedure Performed: Open reduction of nasal fracture

Technique: The patient was taken to the operating room and placed in a supine position. After administering general anesthesia via the orotracheal route, a certified registered nurse anesthetist (CRNA) packed the nose with 4 percent cocaine pledgets and injected it with 1 percent xylocaine with epinephrine. An examination of the nose revealed the nasal dorsum to be depressed and deviated to the right; the nasal septum was also deviated to the right.

The surgeon made a hemitransfixation on the right and elevated the bilateral mucoperichondrial flaps from the septum. Then the surgeon excised the portion of the septum, the maxillary crest, and the ethmoid plate area, allowing the septum to come to a midline position. Next, bilateral medial and lateral osteotomies were performed to release the depressed fracture and elevate the nasal bones.

After adequately elevating the incision, the surgeon closed it with 4-0 chromic, placed septal splints, taped the nose and applied a cast.

Postoperative Diagnosis: Nasal fracture

ICD-9-CM Diagnosis Code Assignment

802.0 Closed fracture of nasal bones

CPT Procedure Code Assignments

For Medicare Patients:

00160 Anesthesia for procedures on nose and accessory

sinuses; not otherwise specified

For Non-Medicare Patients:

21335 Open treatment of nasal fracture; with concomitant open treatment of fractured septum

Note: Because a nonmedically directed certified registered nurse anesthetist (CRNA) provided the anesthesia, attach modifier -QZ to code 00160 or 21335, whichever your third-party payer requires. *

Dawn Seelye is a senior health care consultant with Medical Learning Inc. (MedLearn), St. Paul, MN.

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