SPECIALTY TIP #15 Anesthesiology

Transcription

1 ICD- 10 SPECIALTY TIPS SPECIALTY TIP #15 Anesthesiology The Basics Anesthesia coding is distinctive in that, while the codes may be relatively straightforward, a great many details gleaned from the documentation go into the final assignment of codes and modifiers that represent the services provided. Complete documentation is a safeguard to ensure that all safety measures were followed, aids in the outcome of any potential litigation, and supports the appropriate code choices resulting in prompt, accurate reimbursement for your services. The old adage of If it s not documented, it wasn t done! applies equally to Anesthesiology. There can be no assumptions when it comes to coding. Over 8,000 CPT codes are represented by just over 270 anesthesia codes. These anesthesia (ASA) codes are based on anatomical areas with further divisions based on type of surgeries (arthroscopic, open, closed, etc.), with even further divisions based on the additional complexity of providing anesthesia (one lung ventilation, with pump oxygenator, sitting position, etc.). Truly unique to Anesthesiology is the method of arriving at the fee for the anesthesia service performed. While other specialties have a set fee/reimbursement for the procedure performed, Anesthesia fees are the result of a formula. Each component in this formula is further detailed below. This formula is: The number of base value units of a procedure + The number of time units for the entire procedure + Any additional applicable units (physical status, qualifying circumstances) x The conversion factor = The Final Fee Billing for Obstetrics can be a bit more complicated as there are no national rules governing the way an anesthesia practice may bill for labor and delivery. The American Society of Anesthesiologists (ASA) has published a list of four billing methods it recommends: Basic units plus patient contact time (insertion, management of adverse events, delivery, and removal) plus one unit hourly. Basic units plus time units (insertion through delivery) subject to a reasonable cap. Single fee. Incremental fees (e.g., 0<2 hrs., 2-6 hrs., >6 hrs.) While OB anesthesia generally is not a focus of government investigations, insurance carriers are beginning to question higher fees for the insertion and monitoring of labor epidurals and, as a result, some larger claims may be held for review. Anesthesiology not only performs anesthesia FOR a procedure, they also PERFORM procedures (lines, blocks, emergent procedures, etc.), and E&M services (consults, critical care, trauma services, daily management, pain management, etc.). We have addressed the E&M coding in Specialty Tip #13, consults were addressed in Specialty Tip #8, and post- operative pain management in Specialty Tip #7 so while these may be mentioned, these topics will not be detailed here. In the following, we will cover what coding looks for to arrive at the final code and modifier choices with additional information to explain why those details are important. While this article is extensive, it obviously doesn t cover in minute detail all that goes into coding for Anesthesia but we have tried to give a good overview. What Does Coding Look For? The anesthesia care package consists of preoperative evaluation, standard preparation and monitoring services, administration of anesthesia, and post- anesthesia recovery care. The preoperative evaluation contains a great deal of information surrounding potential co- morbid conditions. It should contain sufficient history and physical examination so that the risk of adverse reactions can be minimized, alternative approaches to anesthesia planned, and all questions regarding the anesthesia procedure by the patient or family answered. The pre- anesthesia evaluation is considered a part of the anesthesia service and is included in the base unit value of the anesthesia code. If information is obtained from anyone other than the patient, note why and from whom ( Patient comatose, history from spouse, History unobtainable, patient with altered mental status, no one else available ). If surgery is cancelled, subsequent to the preoperative evaluation, payment may be allowed to the anesthesiologist for an evaluation and management service and the appropriate E&M code may be reported based on the physician s documentation of history, exam, and medical decision- making. (See Specialty Tip #13 for E&M code details.) (A non- medically directed CRNA may also report an E&M code under these circumstances if permitted by state law.) Postoperative evaluation and management services related to the surgery are not separately reportable by the anesthesia practitioner except when an anesthesiologist provides significant, separately identifiable ongoing critical care services unrelated to the surgery. ANESTHESIOLOGY 1 of 9

2 ICD- 10 SPECIALTY TIPS There is the potential for missing vital information without a legible document. Remember, each anesthesia record is completely reviewed in order to capture a great deal of information which includes: The date, signature(s), and times for the case (start and stop times) o Be sure your signature and title are legible in order to appropriately credit your service Who was involved? (Anesthesiologist, CRNA, Resident) o Was there a change in providers during the case? Who did what and when? Was the case medically directed and is there appropriate documentation to indicate presence for the important aspects of the case? (See the criteria for medical direction below) Concurrency (how many cases were performed or medically directed during the same time frame by the Anesthesiologist) Type of anesthesia administered o Types of anesthesia include regional, epidural, general, moderate conscious sedation (some CPT codes include moderate sedation), or monitored anesthesia care (MAC) o While it is not often used anymore, please keep in mind that combined anesthesia may not easily be discernable and the epidural component might be mistaken as a post- operative pain management procedure. Documenting this method, if used, would help the coder and avoid a query regarding a request for procedure detail. The procedure performed with the highest value to the anesthesiologist (not necessarily the same as the surgeons, particularly in trauma cases) is used for both the CPT and ASA codes o Note procedures with unique requirements (one lung ventilation, field avoidance, unusual positioning) o Watch that the pre- operative procedure planned may have changed during the surgery (arthroscopic converted to open procedure) that may impact the code choice Details of procedures can significantly change the code selection and possibly the base value Open vs. Closed (or converted to open) / Anterior vs. posterior / Diagnostic vs. open or surgical Open vs. Percutaneous vascular procedures Open vs. Transcatheter cardiac procedures Thoracic vs. Abdominal approach THA vs. revision of hip (difference of 2 units) Upper vs. Lower abdomen (generally accepted that belly button is dividing line of organ under surgery) - Upper Abdomen: Spleen, pancreas, gallbladder, small intestines, colon to sigmoid The colon is considered upper unless work is exclusively on sigmoid or rectum - Lower Abdomen: Sigmoid, rectum, uterus, fallopian tubes, bladder and appendix Specify location for incisional or ventral hernias same value (6), but different codes Rigid vs. flexible esophagoscopy (1 unit difference) Breast procedures, radical or modified radical vs. reconstructive (no unit difference, but different codes) - With internal mammary node dissection (8 unit difference) Spine surgery, with or without instrumentation or multiple levels (8-13 units depending on procedure details) Positioning (sitting for open cervical or intracranial procedures) With or without 1 lung ventilation (3 unit difference) - Diagnostic vs. Surgical (4 unit difference) With or without pump oxygenator (5-7 unit difference depending on procedure details) - For procedures on heart, pericardial sac, or great vessels of chest with pump oxygenator with hypothermic circulatory arrest (10 unit difference) Upper 2/3 of femur vs. Lower 1/3 of femur (1 unit difference) Total body surface area (TBSA) for burn excision or debridement (<4%=3 units, between 4% and 9%=5 units, each additional 9% or part=+1 unit) Specific location of hardware removal procedures (superficial or deep) (codes can range from 3 to 8 units depending on location) With or without water bath for lithotripsy (2 unit difference) Angiography only vs. Angiography w/ intervention procedures (i.e., angioplasty, stent, antherectomy) Include diagnoses (see Diagnosis section for details) and any significant conditions reported that would contribute to the complexity of caring for the patient during the case (CAD, COPD, DM, anxiety, etc.) o Keep in mind that the post- op diagnosis may change from the indication for surgery Modifying factors (physical status, qualifying circumstances) Additional procedures (Art lines, CVP, Swan Ganz, Epidurals or blocks for post pain management only) o WHO performed the procedures? This is especially important when multiple providers are involved in the case. Notes to indicate any problems during the case that might indicate a delay in the case or hand- off to the PACU/ICU staff o As a general rule, if more than 15 minutes pass from the anesthesia start time to the time the patient is taken to the operating room, OR time and start of surgery, or 5-15 minutes transferring the patient to the PACU or ICU, the prolonged delay should be explained in the notes. Example: Remained with the patient in PACU until elevated blood pressure stabilized ) PQRS supporting information on Medicare patients when appropriate ANESTHESIOLOGY 2 of 9

3 ICD- 10 SPECIALTY TIPS Factors that Impact Anesthesia Services Component Base Value Units Time Conversion Factor Description Built into each ASA code is a measure of the complexity of the care needed to provide safe analgesia to a patient. Anesthesia time is defined as the period during which an anesthesia practitioner is present with the patient. It starts when the anesthesia practitioner begins to prepare the patient for anesthesia services in the operating room or an equivalent area and ends when the anesthesia practitioner is no longer furnishing anesthesia services to the patient, that is, when the patient may be placed safely under postoperative care. Anesthesia time is a continuous time period from the start of anesthesia to the end of an anesthesia service. Discontinuous Time: (See detailed information below) Pub , Chapter 12, 100.1, Medicare Claims Processing Manual, Payment for Anesthesiology Services The conversion factor is the amount of money determined by your facility that is charged for each unit of anesthesia care provided Concurrency is defined with regard to the maximum number of procedures that the physician is medically directing within the context of a single procedure and whether these other procedures overlap each other. Concurrency is not dependent on each of the cases involving a Medicare patient. Information Only one ASA code, the one with the highest Base value, can be used in the formula to determine the final fee for service. With multiple procedures, the procedure with the highest Relative Value to the surgeon may not be the highest Base value to anesthesia - It is in your best interest to be specific and list all procedures performed in order to determine which code would have the highest base value. - This is especially true for trauma cases when multiple procedures are performed. Any procedure around the head, neck, or shoulder girdle, field avoidance, or any procedure requiring a position other than supine or lithotomy has a base value of 5 regardless of any lesser Base value indicated in the Relative Value Guide Time is reported in units based on defined time increments - Most common is 15 minutes - Medicare requires time reported in actual minutes, not units Even a one minute overlap can cause a change in concurrency and a resulting decrease in reimbursement No rounding, use one, accurate time source. - Unless the facility has atomic clocks in each room, the probability of all the clocks being accurate or synchronized to the minute is slim. Pre- op evaluation is not included in anesthesia time (this is considered a part of the anesthesia service and is included in the base value of the anesthesia code) From various sources, start time is counted from the moment the practitioner - having completed the preoperative evaluation - starts an intravenous line, places monitors, administers pre- anesthesia sedation or otherwise physically begins to prepare the patient for anesthesia and is in continuous attendance. For post- op pain procedures and line insertions see in category below. Keep in mind that your facility conversion factor may be what you charge per unit but that is certainly not what you may receive in reimbursement as each payer has their own conversion factor per unit and they will reimburse accordingly. The Medicare conversion factor is approximately 32% of the national average commercial payer. For ABEO clients, concurrency is determined by our specially designed MedSuite system on receipt of the entire day of charges. - Concurrency is based on all cases per provider from 0001 to 2400 (midnight to midnight) per day An overlap of even one minute can change concurrency Do not round your time Be sure to document relief times or changes in providers See break out below for the definition of concurrency modifiers (Anesthesia Claim Modifiers) Concurrency All of the above medically directed cases in this example overlap for this anesthesiologist except for the last case In this scenario, each case receives a QK modifier indicating Medical direction of two, three, or four concurrent anesthesia procedures and an AA modifier for the one- on- one case ANESTHESIOLOGY 3 of 9

4 ICD- 10 SPECIALTY TIPS Physical Status Modifiers and Qualifying Circumstances See break- out below for each component Codes Invasive Monitoring Lines While not all carriers recognize these components, they carry value into the difficulty of providing anesthesia to certain patients For Physical Status Modifiers especially of 3 and above, please be sure to document the condition prompting the higher status. Descriptions Arterial Line CVP Centrally Inserted Central Venous Catheter, 5 year or older CVP Centrally Inserted Central Venous Catheter, < 5 years or younger Swan- Ganz Catheter For multiple CVPs, document location for each When using a CVP as an introducer for a Swan, only the Swan is billable (the two codes are bundled) If inserting a Swan and a CVP in separate locations, please document each location Accurately record start and stop time for all procedures in order to determine whether they should or should not be included in concurrency calculations For post- op pain services and/or invasive monitoring lines used with anesthesia, when provided after anesthesia start time but prior to induction or following emergence and before stop time, the time spent performing these services should not be included in anesthesia time and should be subtracted from the total time. Conversely, when the block or lines are provided intra- operatively (after induction and prior to emergence), the time spent placing the line or performing the post- op pain service is not subtracted from total anesthesia time. For separately billable radiology procedures indicate retention of reproducible images ( Image retained ), when appropriate. Check with your facility as to whether the images are automatically included in the medical record or whether you would need to print and include manually. Without this documented, the radiology charge cannot be supported Post- op Pain Management See Specialty Tip #7 for details regarding post- operative pain management Documentation of the detail of procedures is needed. Documentation should include: Indication WHO placed the lines or pain management procedure? - This is especially important with multiple providers Time (start and stop) Location Indication of type of line Site and size of the needle utilized/details of the procedure Use of, when applicable, radiology and retention of image if appropriate Outcome/result Physical Status Modifiers The ASA House of Delegates has approved the following table for the Physical Status Classification system. (Value column added) ASA PS Category Definition ASA I Normal healthy patient ASA II Patients with mild systemic disease ASA III Patients with severe systemic disease ASA IV ASA V ASA VI Patients with severe systemic disease that is a constant threat to life Moribund patients who are not expected to survive without the operation A declared brain- dead patient who organs are being removed for donor purposes Examples, including, but not limited to: Value Healthy, non- smoking, no or minimal alcohol use Mild diseases only without substantive functional limitations. Examples include (but not limited to): current smoker, social alcohol drinker, pregnancy, obesity (30<BMI<40), well- controlled DM/HTN, mild lung disease Substantive functional limitations: One or more moderate to severe diseases. Examples include (but not limited to): poorly controlled DM or HTN, COPD, morbid obesity (BMI 40), active hepatitis, alcohol dependence or abuse, implanted pacemaker, moderate reduction of ejection fraction, ESRD undergoing regularly scheduled dialysis, premature infant PCA<60 weeks, history (>3 months) of MI, CVA, TIA, or CAD/stents Examples include (but not limited to): recent (<3 months) MI, CVA, TIA, or CAD/stents, ongoing cardiac ischemia or severe valve dysfunction, severe reduction of ejection fraction, sepsis, DIC, ARD or ESRD not undergoing regularly scheduled dialysis Examples include (but not limited to): ruptured abdominal/thoracic aneurysm, massive trauma, intracranial bleed with mass effect, ischemic bowel in the face of significant cardiac pathology or multiple organ/system dysfunction 0 Units 0 Units 0 Units 1 Unit 2 Units 3 Units Not all carriers recognize the Physical Status Modifiers ANESTHESIOLOGY 4 of 9

5 ICD- 10 SPECIALTY TIPS Qualifying Circumstances Report situations that make administering anesthesia particularly difficult Code Description Anesthesia for a patient of extreme age, under one year or over 70 Information Value 1 unit Total body hypothermia reduces the oxygen requirement in tissues and organs. It is induced to provide a margin of safety during ischemic insult Anesthesia complicated by utilization of total associated with some complex surgical procedures. Total Body body hypothermia Hypothermia is used to permit total circulatory arrest for complicated procedures in the brain, great vessels, spinal cord and heart. Controlled hypotension is defined as a reduction of the systolic blood Anesthesia complicated by utilization of pressure to mm Hg, a reduction of mean arterial pressure (MAP) to controlled (deliberate) hypotension mm Hg or a 30% reduction of baseline MAP. NOTE: Emergency conditions are defined as cases where a delay in Anesthesia complicated by emergency conditions treatment would result in an increased risk to life or body part. 5 units 5 units 2 units Not all carriers recognize Qualifying Circumstances Discontinuous Time Discontinuous time addresses several scenarios with the same basic premise: Interrupted time taken away from the continuous attendance/monitoring of the patient. Per CMS: In counting anesthesia time...the anesthesia practitioner can add blocks of time around an interruption in anesthesia time as long as the anesthesia practitioner is furnishing continuous anesthesia care within the time periods around the interruption. Example: For post- op pain services and/or invasive monitoring lines used with anesthesia, when provided after anesthesia start time but prior to induction or following emergence and before stop time, the time spent performing these services should not be included in anesthesia time and should be subtracted from the total time. Example: The anesthesiologist begins preparing patient A for the anesthesia service, then finds that patient A's surgery has been delayed 30 minutes because the operating room is occupied. If the anesthesiologist leaves patient A to attend to another patient, anesthesia time for patient A's procedure stops; it resumes when the anesthesiologist returns to patient A and resumes personal attendance. The amount of time away from the patient is subtracted from the total time; be sure this is documented in the record. Medical Direction Criteria CMS rules have uniformly applied medical direction payment rules to concurrent procedures, regardless of whom the anesthesiologist is directing To be covered for medical direction, the anesthesiologist must meet the following seven Medical Direction criteria: Present for: Perform a pre- anesthesia examination and evaluation Performed Pre- Anes. Exam Prescribe the anesthesia plan and Evaluation Initials Prescribed Anes. Plan Take part personally in the most demanding procedures of the anesthesia plan, Initials Important Aspects of Case Initials including where indicated, induction and emergence Monitored case at frequent Ensure that any procedures in the anesthesia plan that s/he doesn t perform are intervals Initials performed by a qualified anesthetist Was immediately available Administration of fluids and/or blood throughout case Initials Interpretation of noninvasive monitoring such as ECG, body When indicated: Induction Initials temperature, blood pressure, oximetry, capnography, and mass Airway Management Initials spectrometry Emergence Initials Monitor the course of the anesthesia administration at frequent intervals Non- Medical Direction/ Remains physically present and available for immediate diagnosis and treatment Supervised Only Initials of emergencies Provide the post- anesthesia care indicated ANESTHESIOLOGY 5 of 9

6 ICD- 10 SPECIALTY TIPS A physician who is concurrently directing the administration of anesthesia to not more than four surgical patients cannot ordinarily be involved in furnishing additional services to other patients. However, the following situations do not substantially diminish the scope of control exercised by the physician in directing the administration of anesthesia to surgical patients: Addressing an emergency of short duration in the immediate area Administering an epidural or caudal anesthetic to ease labor pain Periodic, rather than continuous, monitoring of an obstetrical patient A physician may receive patients entering the operating suite for the next surgery Check or discharge patients in the recovery room Handle scheduling matters However, if the physician leaves the immediate area of the operating suite for other than short durations or devotes extensive time to an emergency case or is otherwise not available to respond to the immediate needs of the surgical patients, the physician s services to the surgical patients are supervisory in nature. [Pub , Chapter 12, 100.1, Medicare Claims Processing Manual, Payment for Anesthesiology Services] Word of caution here: In previously checking with Medicare, they were quite specific in that different floors, separate wings, different buildings, (basically outside of the pre- op holding, OR, ICU adjacent to OR, and PACU areas), are never considered immediate areas as the physician is believed to not be immediately available for emergency situations. NOTE: Not all aspects of induction, emergence, and or airway management may apply for patients that have been previously intubated and sedated (from ED, or ICU s) or for patients receiving regional or MAC, hence the wording where indicated has been included by CMS. While you may not have been physically present for patients previously intubated and sedated, be sure to note in the record (remember, the question of responsibility is always present). Modifiers Anesthesia Claim Modifiers (based on the final concurrency determination) Modifier Description Anesthesia Services performed personally by the anesthesiologist CAUTION: This modifier is currently being closely scrutinized for Medicare claims by the Office of Inspector General (OIG) Included in the OIG Work Plan for 2016 AA Anesthesia services payments for personally performed services We will review Medicare Part B claims for personally performed anesthesia services to determine whether they were supported in accordance with Medicare requirements. We will also determine whether Medicare payments for anesthesia services reported on a claim with the AA service code modifier met Medicare requirements. Physicians report the appropriate anesthesia modifier code to denote whether the service was personally performed or medically directed. (CMS, Medicare Claims Processing Manual, Pub. No , Ch. 12, 50.) Reporting an incorrect service code modifier on the claim as if services were personally performed by an anesthesiologist when they were not will result in Medicare's paying a higher amount. The service code AA modifier is used for anesthesia services personally performed by an anesthesiologist, whereas the QK modifier limits payment to 50 percent of the Medicare- allowed amount for personally performed services claimed with the AA modifier. Payments to any service provider are precluded unless the provider has furnished the information necessary to determine the amounts due. (Social Security Act, 1833(e).) (OAS; W ; W ; W ; various reviews; expected issue date: FY 2016) Information Definition of AA: The physician personally performed the entire anesthesia service alone; The physician is involved with one anesthesia case with a resident, the physician is a teaching physician as defined in 100, and the service is furnished on or after January 1, 1996; The physician is involved in the training of physician residents in a single anesthesia case, two concurrent anesthesia cases involving residents or a single anesthesia case involving a resident that is concurrent to another case paid under the medical direction rules. The physician meets the teaching physician criteria in and the service is furnished on or after January 1, 2010; The physician is continuously involved in a single case involving a student nurse anesthetist; The physician is continuously involved in one anesthesia case involving a CRNA (or AA) and the service was furnished prior to January 1, If the physician is involved with a single case with a CRNA (or AA) and the service was furnished on or after January 1, 1998, carriers may pay the physician service and the CRNA (or AA) service in accordance with the medical direction payment policy; or The physician and the CRNA (or AA) are involved in one anesthesia case and the services of each are found to be medically necessary. Documentation must be submitted by both the CRNA and the physician to support payment of the full fee for each of the two providers. The physician reports the AA modifier and the CRNA reports the QZ modifier for a non- medically directed case. Pub , Chapter 12, 100.1, Medicare Claims Processing Manual, Payment for Anesthesiology Services ANESTHESIOLOGY 6 of 9

7 ICD- 10 SPECIALTY TIPS AD Medical Supervision by a physician; more than 4 concurrent anesthesia procedures G8 Monitored anesthesia care (MAC) for deep complex complicated, or markedly invasive surgical procedures used on 00100, 00160, 00300, 00400, 00532, and cases only when applicable G9 Monitored anesthesia care for patient who has a history of severe cardio- pulmonary condition - utilized whenever the surgeon feels the need for MAC due to a history of advanced cardiopulmonary disease. Documentation of the decision and clinical condition should be present. QK Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals QS Monitored anesthesia care service QX CRNA service; with medical direction by a physician Medical direction of one certified registered nurse anesthetist by an anesthesiologist CRNA service: without medical direction by a physician These services have been performed by a resident under the direction of a teaching physician QY QZ GC This throws all cases into supervised, not medically directed resulting in the charging of only 3 units per case for each involved case and no credit for time units. One additional time unit may be recognized if the physician can document h/she was present at induction. While there are no units or monetary value associated with these modifiers, they are used for MAC cases only to emphasize increased complexity, risk and/or comorbid conditions, such that anesthesia services were considered medically necessary in the case. There is no need to add a MAC (QS) modifier as the G modifier itself indicates MAC. It is in your best interests to indicate when these modifiers are applicable to avoid potential denial of the claim. This is an informational modifier that is used in addition to a claim modifier. Diagnosis Accurate reporting of all applicable diagnoses is very important especially for Anesthesiology. In addition to the medical necessity prompting surgery, they explain the additional difficulties you may encounter in keeping the patient stable while they are undergoing surgery. Particularly for MAC cases, it helps to support the inclusion of your services for cases not necessarily requiring anesthesia under normal circumstances. They support your choice of Physical Status Modifier. They could explain why you placed certain monitoring lines or why a patient needed emergent procedures. Your documentation could possibly support a potentially longer procedure than would normally be anticipated. Every time you wonder if you should document a comorbid condition/ situation or whether you really NEED to be more detailed with your diagnosis, imagine an auditor/ lawyer asking you about the anesthesia and why you did something five years after the surgery. Medical necessity drives and supports services and diagnoses support medical necessity. In addition, the Office of Inspector General (OIG) just initiated a new review area for Medicare patients receiving anesthesia and whether it is reasonable and necessary : CAUTION: Included in the OIG Work Plan for 2016 NEW - Anesthesia services non- covered Services We will review Medicare Part B claims for anesthesia services to determine whether they were supported in accordance with Medicare requirements. Specifically, we will review anesthesia services to determine whether the beneficiary had a related Medicare service. Medicare will not pay for items or services that are not "reasonable and necessary." (Social Security Act, 1862(a)(1)(A)) (OAS; W ; expected issue date: FY 2016) Every procedure code has attached to it (by insurance companies) a number of diagnoses that supports the need for the procedure. Should a primary diagnosis fall outside of that bucket of codes, the claim is deleted from the automatic queue and requires further review. Based on that review, there may be a denial or a request for further information. Either way, there is created a time delay in payment for your services. Within the various Specialty Tips we have presented, quite a few diagnoses have been addressed with the essential details that are needed for specificity. Anesthesiology, in providing service for a wide variety of surgeries, covers the entire ICD- 10- CM book. Below are just a few tips to help in the final determination of your diagnosis codes. Use the post- op diagnosis. ANESTHESIOLOGY 7 of 9

8 ICD- 10 SPECIALTY TIPS Document comorbidities that will impact the patient s condition, contributed to the difficulty in providing anesthesia to the patient, and/or support the choice of Physical Status level of the patient. o Document systemic conditions to support medical necessity for MAC procedures, such as cardiopulmonary disease, and psychological condition such as dementia. Include indications for procedures. Be sure to designate right, left, or bilateral when applicable. Location, location, location...always be site specific and detailed. List circumstances of condition such as type of injury (crushing, degloving, closed head injury with brief loss of consciousness, etc.). Document related, secondary or causal ( due to ) illnesses or conditions whenever appropriate. State acute or chronic, old injury, any descriptive wording that help to illustrate the condition. Acute duodenal ulcer with perforation List social factors influencing diagnoses. o Note tobacco use, abuse, dependence, past history, or exposure with type of tobacco product (cigarette, chewing, etc.). o For alcohol, note use, abuse, history of. Note BAL when influencing case. Document trimester for all pregnant patients and number of weeks of gestation in any setting. For deliveries, note outcome of delivery ( single, liveborn, twins, one liveborn, one stillborn, etc.) and whether full term and uncomplicated. o Note the specific wording of full- term and uncomplicated this means without fetal manipulation or instrumentation. o Outside of a normal, spontaneous vaginal delivery the codes can potentially get more detailed to explain the increased difficulties you are encountering during the delivery. Usually there is a reason for a C/section (fetal distress, prolapse of cord, etc.) unless it is planned (different code) coding would then center on labor & delivery complicated by... For specialties, the condition being treated by the specialist should be sequenced first, which is generally the more acute to him/her. More Diagnosis Tips Complications: Internal device, implant, and graft, mechanical Mechanical/Hardware Infection or inflammation Dislocation of prosthetic joint Injury, upper arm Fractures What kind of device, implant, or graft? Intraoperative or Postoperative? Specify nature of the complication: Breakdown Hemorrhage Obstruction Displacement Pain Perforation Osteolysis Stenosis Protrusion Wear of articular bearing Embolism surface Leakage Needs specifics: Laterality? Type of injury? (Abrasion, bite, blister, contusion, external constriction, foreign body, sprain, tear, etc.) Muscle, tendon, fascia? Context of injury? Acute or chronic, traumatic or non- traumatic? Codes for fractures are classified on the basis of following information: Traumatic or Pathologic (+ underlying condition)? Specific anatomical information (which bone and which portion of bone [proximal, shaft, distal, etc.) Type of fracture (colles, torus, etc.) Closed or open, malunion, nonunion - For open fx of forearm, femur, lower leg only, we need additional information for: - Wound size (<1 cm or >1 cm) - Minimal, moderate, or extensive soft tissue injury Displaced or non- displaced? Right, Left, or Bilateral? Are there any retained foreign bodies? ANESTHESIOLOGY 8 of 9

9 ICD- 10 SPECIALTY TIPS Cataract Laterality? H26.9 Unspecified Cataract - Try to avoid in favor of more specificity Type? Infantile Presenile (H ) [Combined forms, cortical, nuclear, subcapsular polar (anterior or posterior?)] Age related Senile (H25.- ) [Nuclear, incipient, cortical, Hypermature, or unspecified?] Complicated (H26.2- ) [With neovascularization or ocular disorder? Glaucomatous flecks?] Diabetic, Type I (E10.36), Type II (E11.36) Myotonic (G71.19/H28) Nuclear Embryonal (Q12.0) or sclerosis (H25.1) Secondary (H26.40) Traumatic (H26.1 [Localized, partially resolved, or total?] with details of injury Resources: and- Guidance/Guidance/Manuals/downloads/clm104c12.pdf Chapter II, Anesthesia Services The information provided is only intended to be a general summary and not intended to take place of either written law or regulations. ANESTHESIOLOGY 9 of 9