Chapter 16: CPT® Section Anesthesia Workbook Case 1 Answer and Rationale.
Case 1
Anesthesiologist personally performed |1|
Anesthesia Time: 7:12 to 10:08 |2|
Physical Status: 2 |3|
Preoperative Diagnosis: Suspected Prostate Cancer
Postoperative Diagnosis: Prostate Carcinoma |4|
Procedure: Radical Retropubic Prostatectomy |5|
Anesthesia: General |6|
|1| Personally performed by anesthesiologist — use AA modifier.
|2| Time is 176 minutes.
|3| Physical status 2, use P2 modifier.
|4| Postoperative diagnosis.
|5| Procedure performed. Make note the procedure is “radical.”
|6| General anesthesia.
What CPT® and ICD-10-CM codes are reported for the anesthesiologist?
CPT® Code: 00865-AA-P2
ICD-10-CM Code: C61
What is the time reported for this service? 176 minutes
Rationale:
CPT® Code: The procedure performed is a radical retropubic prostatectomy. The prostate is considered
extraperitoneal in the lower abdomen. Look in the CPT® Index for Anesthesia/Prostatectomy/Radical referring you to 00865.
P2 is used to report the physical status level 2. AA is used to report the anesthesiologist personally performed the anesthesia.
ICD-10-CM Code: In the ICD-10-CM Alphabetic Index, look for Carcinoma. You are directed to see also Neoplasm, by site,
malignant. In the ICD-10-CM Table of Neoplasms, look for Neoplasm, neoplastic/prostate and report the code from the
Malignant Primary column: C61. Verify code selection in the Tabular List.
Time: The start time is 7:12. The end time is 10:08. This calculates to 2 hours and 56 minutes, or 176 minutes.
Case 2
Anesthesia Start: 14:07 Anesthesia End: 17:33 |1|
Physical Status: 3 [2]
Anesthesiologist: Michael D, MD |2|
Operative Report
Preoperative Diagnosis: Lumbar spinal stenosis
Postoperative Diagnosis: L4-L5 spinal stenosis |3|
Procedure: L4-L5 laminectomy, removal of synovial cyst, bilateral medial facetectomy and posterolateral fusion L4-L5 with
vertebral autograft, bone morphogenic protein, chip allograft, all with intraoperative somatosensory evoked potentials,
electromyographies and loupe magnification. |4|
Anesthesia: General endotracheal anesthesia. |5|
Description of Procedure: The patient was taken to the operating room and underwent intravenous anesthetic and orotracheal
intubation. Her head was placed in the three-pin Mayfield headrest. She was turned into the prone position on a four-poster frame.
All pressure points were carefully padded. The fluoroscope was brought in and sterilely draped to help localize the incision.
A midline incision was made between L4 and L5 through skin and subcutaneous tissue and the paraspinal muscles were dissected
free of the spinous process, lamina, facets and L4, L5 transverse processes. Self-retainers were placed more deeply. We proceeded
to use the double-action rongeur to remove the L4-L5 spinous process lamina. 3 and 4 millimeter Kerrison punches were used
to complete the laminectomy including removing the hypertrophied ligamentum flavum. We made sure that we decompressed
from the top of the L4 pedicle to the bottom of the L5 pedicle, which was confirmed with intraoperative fluoroscopy. The medial
facets were drilled and then we undercut over the nerve roots with a 3 millimeter Kerrison punch. Hemostasis was achieved with
powdered Gelfoam. We irrigated the wound. We decorticated the L4 and L5 transverse processes. We placed our vertebral autograft,
bone morphogenic protein and chip allograft in the posterolateral gutters. Hemovac drain was placed. We closed the muscle with 0
Vicryl. Fascia was closed with 0 Vicryl. Subcutaneous tissue was closed with 2-0 Vicryl and the skin was closed with staples.
|1| Total anesthesia time 3 hours 26 minutes, or 206 minutes.
|2| Physical status 3, use modifier P3.
Personally performed by the anesthesiologist, use modifier AA.
|3| Postoperative diagnosis of lumbar (L4-L5) stenosis.
|4| The following procedures were performed: L4-5 laminectomy, removal of synovial cyst, bilateral medial facetectomy and
posterolateral fusion L4-L5 with vertebral autograft, bone morphogenic protein, chip allograft, all with intraoperative
somatosensory evoked potentials, electromyographies and loupe magnification. The Laminectomy is more complex and carries
a higher base value.
|5| Type of anesthesia is general.
What CPT® and ICD-10-CM codes are reported for the anesthesiologist?
CPT® Code: 00630-AA-P3
ICD-10-CM Code: M48.061
What is the time reported for this service? 206 minutes.
Rationale:
CPT® Code: The following procedures were performed: L4-L5 laminectomy, removal of synovial cyst, bilateral
medial facetectomy and posterolateral fusion L4-L5 with vertebral autograft, bone morphogenic protein, chip allograft,
all with intraoperative somatosensory evoked potentials, electromyographies and loupe magnification. Look in the CPT®
Index for Anesthesia/Spine and Spinal Cord/Lumbar referring you to codes 00630-00635, 00640, 00670. The most complex
procedure performed is the laminectomy which is reported with 00630. Modifier AA is used to indicate the anesthesia
service was personally performed by the anesthesiologist. Modifier P3 is used to indicate a level 3 physical status.
Anesthesia modifiers always precede physical status modifiers.
ICD-10-CM Code: The postoperative diagnosis is L4-L5 Spinal Stenosis. L4-L5 is in the lumbar region. To locate the ICD-10-CM
code, look in the Alphabetic Index for Stenosis, stenotic/spinal/lumbar region referring you to M48.061. Verify code selection
in the Tabular List.
Time: The start time is 14:07 (2:07 pm) and the end time is 17:33 (5:33 pm). This time calculates to 3 hours and 26 minutes or
206 minutes.
Case 3
Anesthesiologist personally performed case |1|
Anesthesia Time: 13:04 to 13:41 |2|
Physical Status: 3 |3|
Preoperative Diagnosis: RLL Lung Cavity, possible CA of lung
Postoperative Diagnosis: Right Lower Lobe Lung Carcinoma |4|
Procedure: Bronchoscopy |5|
Anesthesia: Monitored anesthesia care |6|
Procedure Description: With the patient under satisfactory anesthesia, a flexible fiberoptic bronchoscope was introduced via oral
cavity and advanced past the larynx for visualization of the bronchus. Cell washings were obtained and sent to pathology. The
bronchoscope was then removed. Patient tolerated procedure well.
Cell washings obtained from the right lower lobe were confirmed by pathology as malignant carcinoma.
|1| Use modifier AA to indicate the anesthesiologist personally performed the case.
|2| Anesthesia time is 37 minutes.
|3| Physical status 3 — use P3 modifier.
|4| Postoperative diagnosis confirms RLL CA.
|5| Procedure performed.
|6| Use modifier QS to indicate monitored anesthesia care was used.
What CPT® and ICD-10-CM codes are reported for the anesthesiologist?
CPT® Code: 00520-AA-QS-P3
ICD-10-CM Code: C34.31
What is the time reported for this service? 37 minutes.
Rationale:
CPT® Code: Look in the CPT® Index for Anesthesia/Bronchoscopy referring you to 00520. Modifier AA is used to
indicate the anesthesia service was personally performed by the anesthesiologist. Modifier QS is used to indicate MAC was
used. Modifier P3 is used to indicate the patient is physical status 3. Anesthesia modifiers are always listed first, followed by
the MAC modifier QS. Physical status modifiers are listed last.
ICD-10-CM Code: The diagnosis is confirmed as RLL CA. Look in the ICD-10-CM Alphabetic Index for Cancer – see also
Neoplasm, by site, malignant. Look in the Table of Neoplasms for Neoplasm, neoplastic/lung/lower lobe and select the code
from the Malignant Primary column: C34.3-. In the Tabular List, 5th character 1 is reported for the right lung.
Time: The start time is 13:04. The end time is 13:41. The time calculates to 37 minutes.
Case 4
Anesthesia services personally provided by anesthesiologist |1|
Physical Status: 2 |2|
Anesthesia Start: 10:03 |3| Anesthesia Stop: 11:06 |3|
Preoperative Diagnosis: Sternal wound hematoma.
Postoperative Diagnosis: Complicated upper abdominal wall wound. |4|
Name of Procedure: Sternal wound exploration and wound vac placement. |5|
Anesthesia: Monitored Anesthesia Care |6|
Brief History: He is a 52-year-old patient who is two weeks out from re-do sternotomy and aortic valve replacement for critical aortic
stenosis in the setting of heart failure. He had a postoperative coagulopathy and required sternal re-exploration with open packing.
|7| He was closed the next day. He had serous discharged prior to going home but this was culture negative and the wound looked
very good. He continued to have serous discharge in the clinic and it was felt he had a retained hematoma. He was scheduled for
evaluation of the hematoma and wound vac placement. This was done without incident. He did not have any evidence of infection.
There was no evidence of any sternal instability.
Description of Operative Procedure: Following delivery of the patient to the operating room, the patient was placed on the
operating table, prepared and draped in the usual sterile manner. His upper abdominal wound was explored. There was hematoma
at the base of the wound which was very carefully evacuated |8| and the wound was irrigated with antibacterial solution. A wound
vac was then placed with the assistance of the wound care nurse. |9| The patient was returned to the PCU in stable condition.
|1| Use modifier AA to indicate the anesthesia was personally performed by the anesthesiologist.
|2| Physical status 2, use modifier P2.
|3| Anesthesia time is 1 hour and 3 minutes, or 63 minutes.
|4| Postoperative diagnosis used for coding if no other indication is found in the operative note.
|5| Procedure performed.
|6| Use modifier QS to indicate MAC is used.
|7| The wound is a postoperative complication.
|8| Confirms a postoperative hematoma.
|9| Wound vac placed by a wound care nurse.
What CPT® and ICD-10-CM codes are reported for the anesthesiologist?
CPT® Code: 00700-AA-QS-P2
ICD-10-CM Code: L76.32
What is the time reported for this service? 63 minutes.
Rationale:
CPT® Code: In the CPT® Index, look for Anesthesia/Abdomen/Abdominal Wall referring you to a range of codes.
This is an upper abdominal wound from a sternal (anterior) procedure. 00700 is the correct code. Anesthesia modifier AA
indicates that the anesthesiologist personally performed the anesthesia care. Anesthesia modifiers are always placed first.
The QS modifier indicates MAC, and the physical status P2 is listed last.
ICD-10-CM Code: The diagnosis is listed as a complicated abdominal wound; however, the body of the note indicates it
is a retained hematoma from the procedures two weeks prior. Look in the ICD-10-CM Alphabetic Index for Hematoma/
postoperative – see Complication, postprocedural, hematoma; Complication/postprocedural/hematoma (of)/skin and
subcutaneous tissue/following a procedure on other organ directs you to L76.32. Verify code selection in the Tabular List.
Time: The start time is 10:03. The end time is 11:06. This calculates to 1 hour and 3 minutes, or 63 minutes.
Case 5
Anesthesia Start: 12:18 |1| Anesthesia End: 13:31 |1|
CRNA: John Sleep, CRNA (Non-Medically Directed) |2|
Physical Status: 3 |3|
Operative Report
Preoperative Diagnosis: Stricture of the left ureter, postoperative
Postoperative Diagnosis: SAME |4|
Procedure:
1. Cystoscopy of ileal conduit.
2.Exchange of left nephroureteral catheter.
Anesthesia: Monitored anesthesia care. |5|
Description of Procedure: The patient is identified in the holding area, marked, taken to the operating room. Subsequently, she
was given monitored anesthesia care. She was prepped and draped in the usual sterile fashion in the supine position. Next, using
a flexible cystoscope, the ileal conduit was entered. Cystoscopy was performed, which showed the ureteroileal anastomosis on
the left with a stent protruding from it. There were no calcifications seen on the stent. Thus, the cystoscope was removed from the
ileal conduit and then a super stiff wire was advanced through the nephroureteral catheter, up into the kidney. Once it was up
there, then the catheter was taken off of the wire and then a new 8-French x 28-centimeter, nephroureteral ureteral catheter was
advanced fluoroscopically into the level of the kidney. Once this was done and its position was confirmed fluoroscopically, the wire
was pulled. A good curl was there fluoroscopically in the kidney, as the wire was pulled. A good curl was seen in the bladder and
then the distal end was protruding out from the ileal conduit. This was placed in the ostomy bag and the patient was taken in stable
condition to the recovery room.
|1| Report anesthesia time in minutes.
|2| Modifier QZ used to indicate services are performed by a CRNA with no medical direction.
|3| Physical status 3 — use modifier P3.
|4| Postoperative diagnosis is the same as preoperative which is stricture of the left ureter, postoperative.
|5| Modifier QS is used to indicate MAC.
What CPT® and ICD-10-CM codes are reported for the CRNA?
CPT® Code: 00860-QZ-QS-P3
ICD-10-CM Code: N13.5
What is the time reported for this service? 73 minutes.
Rationale:
CPT® Code: Both a cystoscopy and exchange of ureteral stent via ilealoconduit were performed. The ureteral
stent was more complex and carries a higher base value. The ureter is part of the urinary system. Look in the CPT® Index for
Anesthesia/Urinary Tract, and you are directed to 00860. Anesthesia modifier QZ indicates the CRNA was without medical
direction. Modifier QS is reported to show MAC. The physical status was 3.
ICD-10-CM Code: The diagnosis is a stricture of the left ureter, postoperative. Look in the ICD-10-CM Alphabetic Index for
Stricture/ureter (postoperative) and you are directed to N13.5. Verification in the Tabular List confirms code selection.
Time: The start time is 12:18. The end time is 13:31. This calculates to 73 minutes.
Case 6
CRNA performed anesthesia |1|
Anesthesiologist medically directing |1| two cases |2|
Anesthesia Time: 9:30 to 10:06
Physical Status: 3 |3|
Preoperative Diagnosis: Cyst behind knee
Postoperative Diagnosis: Baker’s cyst |4|
Procedure: Excision of Baker’s cyst, knee |5|
Anesthesia: Monitored Anesthesia Care |6|
|1| Use Modifier QX to indicate CRNA services with medical direction by a physician.
|2| Use modifier QK to indicate medical direction of two cases by anesthesiologist.
|3| Physical status 3 — use P3 modifier.
|4| Use postoperative diagnosis.
|5| Excision is an open procedure and is performed on the knee.
|6| MAC services require QS modifier.
What CPT® and ICD-10-CM codes are reported for the anesthesiologist?
CPT® Codes: 01400-QK-QS-P3
ICD-10-CM Code: M71.20
What CPT® and ICD-10-CM codes are reported for the CRNA?
CPT® Code: 01400-QX-QS-P3
ICD-10-CM Code: M71.20
What is the time reported for this service? 36 minutes
Rationale:
CPT® Codes: Look in the CPT® Index for Anesthesia/Knee referring you to a large selection of codes. Other
than 00400 (used for Integumentary), the codes directed fall within the range 01320-01444 (knee and popliteal area). An
excision is an open procedure, so find the code specific to open procedures on the knee. There is not a specific anesthesia
code for excision of a Baker’s cyst. A Baker’s cyst occurs at the back of the knee and involves the buildup of synovial fluid
from the knee joint, so CPT® 01400 is reported. The physical status is reported as level 3 (P3). QK is used to indicate the
anesthesiologist is directing 2-4 concurrent cases. QX is used to indicate the services reported by the CRNA. QS reports
Monitored Anesthesia Care (MAC) services.
ICD-10-CM Code: The postoperative diagnosis is Baker’s cyst. In the ICD-10-CM Alphabetic Index, look for Cyst/Baker’s
referring you to M71.2-. In the Tabular List, 5th character 0 is reported for unspecified knee.
Time: The anesthesia time is noted as 9:30-10:06, which is 36 minutes.
Case 7
CRNA performed anesthesia under medical direction of anesthesiologist |1|
Anesthesiologist medically directing one case |2|
CRNA placed arterial line |3|
Anesthesia Time: 10:43 to 12:50 |4|
Physical Status: 3 |5|
Preoperative Diagnosis: Left Renal Mass
Postoperative Diagnosis: Same |6|
Procedure: Left Partial Nephrectomy, Laparoscopic |7|
Anesthesia: General |8|
Procedure Description: Abdominal wall insufflated. The laparoscope was placed through the umbilical port and additional trocars
were placed into the abdominal cavity. Using the fiberoptic camera, the renal mass was identified and the diseased kidney tissue
was removed using electrocautery. Minimal bleeding is noted. Instruments were removed and the abdominal incisions were closed
by suture. Patient tolerated surgery well and was transferred to the Post Anesthesia Care Unit in satisfactory condition.
|1| QX (CRNA with medical direction by a physician).
|2| QY (medical direction of one CRNA by an anesthesiologist).
|3| Arterial line placed by CRNA.
|4| Report the anesthesia time in minutes.
|5| Use physical status modifier P3.
|6| Postoperative diagnosis is the same as the preoperative diagnosis — left renal mass.
|7| Procedure performed.
[8] General anesthesia.
What CPT® and ICD-10-CM codes are reported for the anesthesiologist?
CPT® Code: 00862-QY-P3
ICD-10-CM Code: N28.89
What CPT® and ICD-10-CM codes are reported for the CRNA?
CPT® Codes: 00862-QX-P3, 36620
ICD-10-CM Code: N28.89
What is the time reported for this service? 2 hours and 7 minutes, or 127 minutes
Rationale:
CPT® Codes: Look in the CPT® Index for Anesthesia/nephrectomy referring you to 00862. Verification of the code
confirms this code is for anesthesia for renal procedures. The anesthesiologist was medically directing one CRNA; therefore,
QY is appended to 00862. The medically directed CRNA service is reported with modifier QX. The anesthesia modifiers
always precede the physical status modifier. The CRNA also inserted an A-Line (arterial line) which is coded separately with
36620. Look in the CPT® Index for Cannulation/Arterial directing you to 36620, 36625.
ICD-10-CM Code: The postoperative diagnosis is kidney mass. (Do not code mass as neoplasm — coding instructions indicate
to see disease of specified organ when not listed under mass.) Look in the ICD-10-CM Alphabetic Index for Mass/kidney
referring you to N28.89. Verify code selection in the Tabular List.
Time: The start time is listed as 10:43. The end time is listed as 12:50. This calculates to 2 hours and 7 minutes or 127
minutes.
Case 8
CRNA performed anesthesia under medical direction of anesthesiologist |1|
Anesthesiologist medically directing three cases |2|
Anesthesia Time: 8:52 to 9:34 |3|
Physical Status: 1 |4|
Preoperative Diagnosis: Phimosis, congenital
Postoperative Diagnosis: Phimosis, congenital |5|
Procedure: Circumcision on six-month-old boy |6|
Anesthesia: Monitored anesthesia care |7|
|1| QX (CRNA service with medical direction by a physician).
|2| QK (Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individual).
|3| Report anesthesia time in minutes.
|4| Physical status 1, use modifier P1.
|5| Postoperative diagnosis is used for coding.
|6| Circumcision (6-month-old child — don’t forget about age for qualifying circumstances).
|7| Monitored Anesthesia Care (Requires QS modifier.).
What CPT® and ICD-10-CM codes are reported for the anesthesiologist?
CPT® Codes: 00920-QK-QS-P1, 99100
ICD-10-CM Code: N47.1
What CPT® and ICD-10-CM codes are reported for the CRNA?
CPT® Code: 00920-QX-QS-P1
ICD-10-CM Code: N47.1
What is the time reported for this service? 42 Minutes
Rationale:
CPT® Codes: The procedure is circumcision. Look in the CPT® Index for Anesthesia for Genitalia/Male referring
you to code range 00920-00938. There is not a code specific to circumcision, so 00920 is used. The patient is six months old
and the qualifying circumstance for extreme age (99100) is reported. The qualifying circumstance is only reported for the
anesthesiologist. Modifier QS is appended to indicate Monitored Anesthesia Care (MAC). The physical status is stated as 1, so
modifier P1 is appended. Modifier QK is appended to the anesthesiologist’s code to indicate medical direction of two, three,
or four concurrent anesthesia procedures involving qualified individuals. Modifier QX is appended to the CRNA’s services to
indicate the CRNA is performing under the medical direction of an anesthesiologist. The anesthesia modifier is placed first,
followed by QS, with the physical status modifier placed last.
ICD-10-CM Code: The diagnosis is phimosis. Look in the ICD-10-CM Alphabetic Index for Phimosis (congenital) (due to
infection) directing you to N47.1. Verification of this code in the Tabular List confirms code selection.
Time: The anesthesia time is noted as 8:52-9:34, which is 42 minutes
Case 9
Non-medically directed CRNA |1| performed anesthesia and documented intra-operative placement of continuous femoral nerve
catheter for post operative pain. |2|
Anesthesia Time: 7:18 to 9:10 |3|
Physical Status: 3 |4|
Preoperative Diagnosis: Left knee osteoarthritis
Postoperative Diagnosis: Left knee osteoarthritis, localized primary, |5| Acute post-operative pain |6|
Procedure: Total knee arthroplasty |7|
Anesthesia: General anesthesia |8| provided for surgery. Surgeon requested postoperative pain management via continuous femoral
catheter
|1| CRNA services without medical direction require modifier QZ.
|2| Anesthesia and intra-operative placement of continuous femoral nerve catheter.
|3| Calculate anesthesia time in minutes.
|4| Physical status 3 requires P3 modifier.
|5| Primary diagnosis is specified as left knee osteoarthritis, localized, primary.
|6| Diagnosis of acute postoperative pain gives medical necessity for the intra-operative placement of continuous femoral nerve
catheter.
|7| The procedure is total knee arthroplasty NOT arthroscopy, which carries a lower base value.
|8| Anesthesia provided is general.
What CPT® and ICD-10-CM codes are reported for the CRNA?
CPT® Codes: 01402-QZ-P3, 64448-59-LT
ICD-10-CM Codes: M17.12, G89.18
What is the time reported for this service? 112 minutes
Rationale:
CPT® Codes: Look in the CPT® Index for Anesthesia/Arthroplasty/Knee referring you to 01402. P3 indicates a
physical status level 3. Modifier QZ is used to indicate the services were performed by a CRNA without medical direction.
The intra-operative placement of continuous femoral nerve catheter is separate from the general anesthesia used for the
surgery; therefore, it is reported separately. The catheter is placed for management of the postoperative pain via continuous
femoral catheter. Look in the CPT® Index for Femoral Nerve/Injection/Anesthetic directing you to 64447-, 64448. CPT® 64448
is for the continuous infusion by catheter and includes the catheter placement. Modifier 59 is appended to indicate it is a
separate procedure from the general anesthesia used for the surgery. Modifier LT is appended to indicate femoral nerve in
the left leg. The CMS bilateral indicator for 64448 is one allowing modifier RT and LT to be appended.
ICD-10-CM Codes: The diagnosis for the general anesthesia is left knee osteoarthritis, localized, primary. Look in the
ICD-10-CM Alphabetic Index for Osteoarthritis/primary/knee to find M17.1-. In the Tabular List, 5th character 2 is reported for
the left knee. To report the acute postoperative pain, look in the Alphabetic Index for Pain(s)/postoperative NOS referring you
to G89.18. Verify code selection in the Tabular List.
Time: The start time is 7:18 and the end time is 9:10. This calculates to 1 hour 52 minutes, or 112 minutes.
Case 10
CRNA directly supervised by anesthesiologist |1| who is directing two other cases. |1|
CRNA inserted a separate CVL, |2| Swan-Ganz catheter, |2| and an A-line |2|
Patient has a severe systemic disease that is a constant threat to life |3|
Anesthesia Time: 11:43 to 15:26 |4|
Preoperative Diagnosis: Multivessel coronary artery disease.
Postoperative Diagnosis: Coronary artery disease, native artery |5|
Name of Procedure: Coronary artery bypass graft x 3, left internal mammary artery to the LAD, saphenous vein graft to the obtuse
marginal, saphenous vein graft to the diagonal.
Anesthesia: General |6|
Brief History: This 77-year-old patient who was found to have a huge aneurysm. Preoperative cardiac clearance revealed a markedly
positive stress test and cardiac catheterization showed critical left-sided disease. Coronary revascularization was recommended.
The patient has multiple medical illnesses including chronic obstructive pulmonary disease with emphysema and chronic renal
insufficiency. I discussed with the patient and the family, the risks of operation including the risk of bleeding, infection, stroke,
blood transfusion, renal failure, and death. At operation, we harvested a vein from the left leg using an endoscopic technique that
turned out to be a very good conduit. Her obtuse marginal vessel was a 1.5 mm diffusely diseased vessel that was bypassed distally
as it ran in the left ventricular muscle. The diagonal was a surprisingly good vessel at 1.5 mm in size. The LAD was bypassed in the
mid aspect of the LAD and there was distal disease though a 1.5 mm probe passed quite easily. Good flow was measured in the
graft. The patient came off bypass very nicely. Note should be made that her ascending aorta was calcified and we used a single
clamp technique.
Description of Operative Procedure: Following delivery of the patient to the operating room, the patient was placed under general
anesthetic, was prepped and draped in the usual sterile manner. Arterial line through the skin, right pulmonary artery catheter
and a left subclavian central lines were placed by the Anesthesia Department. |7| A median sternotomy was made and the left
internal mammary artery was harvested from the left chest wall, the saphenous vein was harvested from the left leg. The patient
was heparinized and cannulated and placed on cardiopulmonary bypass |8| with an aortic cannula on the undersurface of the aortic
arch and a venous cannula through the right atrial sidewall. Note should be made that the upper aorta was very heavily calcified,
but the area that we cannulated was felt to be disease free. The aorta was cross clamped and the heart was stopped with antegrade
and retrograde cardioplegic solution. The heart was retracted out of the pericardial sac and then displaced into the right chest which
afforded good access to the lone marginal vessel which was bypassed with a reversed saphenous vein graft using a running 7-0
Prolene suture. Cold cardioplegic solution was then instilled down this graft. Note should be made that during the mammary artery
harvest, the left lung was completely adherent to the left chest wall, most likely from old episodes of pneumonia. Next, a second
saphenous vein segment was placed to the diagonal vessel and then the left internal mammary artery was placed to the mid LAD.
As noted, there was diffuse calcification distally in this artery just beyond the anastomosis, but the 1.5 mm probe passed very nicely
and we felt that it was not necessary to double jump this LAD. With the cross clamp in place, two proximal aortotomies were made
and the two proximal anastomoses were formed using 6-0 Prolene in a running fashion. Just prior to completion of the second
anastomosis, appropriate de-airing maneuvers were performed and then the suture lines were tied as the cross clamp was removed.
The patient was allowed to rewarm completely and was weaned from bypass. The cannulas were removed and the cannulation
sites were secured with pursestring sutures. Once hemostasis was secured, chest tubes were placed and the wound was closed.
Final needle, instrument, and sponge counts were reported as correct. The patient tolerated the procedure well and returned to the
recovery room in stable condition.
|1| CRNA directly supervised by the anesthesiologist supports modifier QX.
Anesthesiologist was directing two cases this supports the use of modifier QK.
|2| Swan-Ganz is reported separately by the CRNA.
CVL is reported separately by the CRNA.
A-line (Arterial line) is reported separately by the CRNA.
|3| Supports modifier P4 for physical status 4.
|4| Report anesthesia time in minutes.
|5| Postoperative diagnosis should be used for diagnosis reporting.
|6| Anesthesia is general.
|7| Verifies line placement by the anesthesia department.
|8| A bypass machine was used as indicated by “placed on cardiopulmonary bypass.”
What CPT® and ICD-10-CM codes are reported for the anesthesiologist?
CPT® Code: 00567-QK-P4, 99100
ICD-10-CM Code: I25.10
What CPT® and ICD-10-CM codes are reported for the CRNA?
CPT® Codes: 00567-QX-P4, 36556-59, 93503, 36620-51
ICD-10-CM Code: I25.10
What is the time reported for this service? 223 minutes
Rationale:
CPT® Codes: The procedure performed was a CABG (Coronary Artery Bypass Graft). To locate the service in
the CPT® Index, look for Anesthesia/Heart/Coronary Artery Bypass Grafting referring you to 00566, 00567. Selecting
between the two codes depends on the use of a pump oxygenator. The documentation states “…the patient was placed on
cardiopulmonary bypass…” indicating with pump oxygenator. 00567 is the correct anesthesia code. The patient is identified
as having severe systemic disease that is a constant threat to life, supporting a P4 modifier.
For the CRNA, modifier QX is used to report the CRNA service with medical direction. Anesthesia modifiers precede physical
status modifiers. The CRNA placed a central venous catheter in the left subclavian. Look in the CPT® Index for Central
Venous Catheter Placement/Insertion/Central Non-tunneled. Code 36556 is reported because the patient is 77 years old.
Next, a Swanz-Ganz catheter is placed in the right pulmonary artery. Look in the CPT® Index for Swanz-Ganz Catheter/
Insertion referring you to 93503. A central line (36556) is bundled with code 93503. A Swan-Ganz catheter is a central line
with multiple lumens, which is flow-directed into the pulmonary artery. Modifier 59 is required with 36556 to indicate that
this central line is in another site and totally separate from 93503. The CRNA also inserted an A-line (arterial line), which
is coded separately. Look in the CPT® Index for Arterial Catheterization referring you to See Cannulation, Arterial. Look for
Cannulation/Arterial. Code 36620 is the correct for percutaneous insertion through the skin. Anesthesia modifiers are not
used on surgical procedure codes. Modifier 51 is needed on 36620 for additional procedures performed during the same
session.
For the anesthesiologist, modifier QK indicates the medical direction of 2-4 concurrent cases. The anesthesia modifiers
precede physical status modifiers. Code 99100 is also reported due to the patient being 77 years old. There is no indication
that this is a Medicare beneficiary, so 99100 is reported. When directing, only the anesthesiologist reports 99100.
ICD-10-CM Code: The diagnosis is stated as coronary artery disease, native artery. To find the ICD-10-CM code, look in the
ICD-10-CM Alphabetic Index for Disease, diseased/artery/coronary referring you to I25.10. Verify code selection in the
Tabular List.
Time: The anesthesia time is stated as 11:43 to 15:26 (3:26 pm), which calculates to 3 hours 43 minutes or 223 minutes.