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Anesthesia means induction or administratin of a drug to obtain partial or complete loss of sensation. Analgesia (absence of pain) is achieved so that a patient may have surgery or a procedure performed without pain. Types of anesthesia may be general, regional, or local.

Conscious Sedation
Conscious sedation is a type of sedation that can be provided by a physician performing a procedure; it provides a decreseased level of consciousness that does not put the patient completely to sleep. This level of consciousness allows the patient to breathe without assistance and to respond to stimulation and verbal commands. The codes used to report this type of conscious sedation are located in the Medicine section (99141-99142), not in the anesthesia section. If the sedation is provided by a physician other than the physician performing the procedure, you would use the appropriate anesthesia code.

**The conscious sedation codes 99141 or 99142 from the Medicine section are used only when the physician performing the procedure administers the sedation.**

The conscious sedation codes in the Medicine section are divided based on the method by which sedation is achieved. Code 99141 is for intravenous, intramuscular, or inhalation sedation methods. These sedation methods are much less invasive than is the complete loss of consciousness. For example, for a colonoscopy, a physician could administer an intravenous sedation, such as meperidine (Demerol), morphine, or diazepam(Valium). The patient would be monitored closely as the medication is administered so that the appropriate level of sedation is reached. After the procedure the physcian may administer a drug such as (Narcan) intravenously to reverse the effects of the sedation. The patient would have this procedure in an outpatient setting and be able to go home after the procedure.

The last three subsections in Anesthesia--Radiologic Procedures, Burn Excisions or Debridement, and Other procedures--are not by anatomic division. The CPT codes in the Radiologic Procedures subsection of the Anesthesia section are used to report anesthesia service when radiologic services are provided to the patient for diagnostic or therapeutic reasons.

The last three subsections in Anesthesia--Radiologic Procedures, Burn Excisions or Debridement, and Other procedures--are not by anatomic division. The CPT codes in the Radiologic Procedures subsection of the Anesthesia section are used to report anesthesia service when radiologic services are provided to the patient for diagnostic or therapeutic reasons.

Preoperative, intraoperative (care during sugery), and postoperative care are all included in the anesthesia code. If addtional procedures are performed by the anesthesialogist they can be coded in addition to the regular anesthesia code. What makes anesthesia coding different from any other coding is the way in which anesthesia services are billed. There is a standard formula for payment of anesthesia services that is, for the most part, nationally accepted. The formula is basic units + time units + modifying units (B + T + M).

The ASA publishes a Relative Value Guide (RVG), which contains codes for anesthesia services. The CPT manual contains most of these anesthesia service codes in the Anesthesia Section. The RVG includes about 23 anesthesia service codes that are not included in the CPT manual and several codes that have components of the service that vary from the CPT description for the code.
The ASA's RVG is not a fee schedule but instead compares anesthesia services with each other. Anesthesia services provided for a biopsy of a sinus are less complicated than services provided for a radical sinus surgery. A team of physicians with expertise in anesthesiology developed the comparisons and assigned numerical values to each service, termed the basic unit value.
One coding circumstance unique to anesthesia coding occurs when multiple surgical procedures are performed during the same session. In this case the procedure with the highest unit value is the basic unit value. For example, if during the same surgical procedure session a clavicle biopsy (basic unit value of 3) and a radical mastectomy (basic unit value of 5) are done, the basic unit value for both procedures becomes 5.
Another coding circumstance unique to anesthesia coding applies when there is a second attending anesthesiologist (one who performs the same types of services as the first attending physician. In this case a basic value of 5 units is added to report the additional physician's service. A special report must accompany the submission to the third-party payer explaining why the procedure required the services of two anesthesiologists. The time for both anesthesiologists is also reported.

Anesthesia services are provided based on the time during which the anesthesia was administered, in hours and minutes. The timing is started when the anesthesiologist begins preparing the patient to receive anesthesia, continues through the procedure, and ends when the patient is no longer under the personal care of the anesthesiologist. The hours and minutes during which anesthesia was administered are recorded in the patient record. Carriers independently determine the amount of time in a unit.

As the name implies, modifying units reflect circumstances or conditions that change or modify the environment in which the anesthesia service is provided. There are two basic modifying characteristics; qualifying circumstances and physical status modifiers.

Qualifying Circumstances
Sometimes anesthesia is provided in situations that make the administration of the anesthesia more difficult. These types of cases include those that are performed in emergency situations and those dealing with patients of extreme age; they also include services performed during the use of controlled hypotension or the use of hypothermia. The Qualifying Circumstances codes begin with the number 99 and are considered adjunct codes, which means that the codes cannot be used alone but must be used in addition to another code and are used to provide additional information only. The Qualifying Circumstances codes are located in two places in the CPT manual: the Medicine section and the Anesthesia section guidelines. In both locations the plus symbol is located next to the codes (99100-99140), indicatin their status as add-on codes only.

**STOP** You were just presented with some very important information about the use of certain codes in the CPT manual. The plus symbol next to any CPT code- not just next to Qualifying Circumstances codes- indicates that that code cannot be used alone. Throughout the remaining sections of the CPT manual, the plus symbol will appear to caution you to use the code only as an adjunct code (with other codes).

The CPT index lists the qualifying circumstances coded under Anesthesia, Special Circumstances.

Physical Status Modifiers
The second type of modifying unit used in the Anesthesia section is the physical status modifier. These modifiers are used to indicate the patient's condition at the time anesthesia was administered. The physical status modifier not only indicates the patient's condition at the time of anesthesia but also serves to identify the level of complexity of services provided to the patient. For instance, anesthesia service to a gravely ill patient is much more complex than the same type of service to a normal, healthy patient. The physical status modifier is not assigned by the coder but is determined by the anesthesiologist and documented in the anesthesia record. The physical status modifier begins with the letter "p" and contains a number from 1 to 6. Note that the relative value for P1, P2, and p6 is zero because the conditions are considered not to affect the service provided. A physical status modifier is used after the five-digit CPT code.

Let's put the elements of the equation to practical use by applying the equation (B+T+M) to a specific case.
An 84 year old female (qualifying circumstances for extreme age, value 1)with severe hypertension has a 4 cm malignant lesion removed from her right knee (basic value of 3). The total time of anesthesia service was 60 minutes (4 units). The anesthesiologist indicates in the medical record that the patients physical status at the time of the procedure was P3 for a severe systemic disease (relative value of 1)

A conversion factor is the dollar value of each unit. An example of a third-party payer's anesthesia conversion factors. Note that North Dakota is $15.77 per unit and Manhattan, NY, is $20.48 per unit, as it is much less expensive to provide anesthesia services in Grand Forks, ND, than it is to provide the same services in Manhattan, NY.
If the anesthesiologist were located in Manhattan, NY, which has a conversion factor of $20.48, the total for the procedure would be $184.32 (9 x $20.48). If the same services were provided in North Dakota, with the conversion factor of $15.77, the total for the procedure would be $141.93 (9 x $15.77).

The CPT two-digit modifiers are used with anesthesia service codes. Modifier 51, multiple procedures, is not usually used with anesthesia codes because when multiple services are provided during the same anesthesia session, the value assigned to the highest valued service is used to report all services. If services for a value of 10 and 5 were done during the same session, the value of 10 would report all services for that session. In coding within other sections of the CPT, the modifier -51 is added to the second procedure, and usually the third-party payer pays that second service at a reduced rate, but this is not the case in anesthesia.

Concurrent Care Modifiers
When an anesthesiologist is directing the provision of anesthesia in more than one case at a time, modifiers are used to indicate the context and number of cases that are being reported concurrently. The following modifiers are among the most commonly used.
Anesthesia services performed personally by anesthesiologist.
Medical supervision by a physician: more than four concurrent anesthesia procedures.
Certified registered nurse anesthetist (CRNA) service, with medical direction by a physician.
Anesthesiologist medically directs one CRNA
CRNA service, without medical direction by a physician
These modifiers are not CPT modifiers but HCPCS modifiers. These modifiers further define the services provided.

In the anesthesia section, an unlisted procedure code number is available. The unlisted procedure code is located under the Other Procedures subsection in the Anesthesia section.
When a new surgical procedure is used, there is no CPT code to indicate the surgical procedure or the anesthesia services provided during the procedure. The anesthesia services are reported using the lone unlisted anesthesia code - 01999.