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Coding for Anesthesia Services

INTRODUCTION contains numerous updates and modifications. Previous-
It is apparent that confusion exists regarding the proper ly, CDT was a five-digit system, however, in the CDT-3
coding of anesthesia services performed by the OMS. Defi- version the initial zero was changed to a “D.” With the
nitions for levels of sedation and anesthesia may be found reformation of the ADA's Coding Maintenance Commit-
in the AAOMS Parameters of Care, the American Dental tee, CDT will now be updated annually.
Association’s (ADA) Current Dental Terminology (CDT) CPT, CDT and ICD-9-CM are revised annually. The new
Manual and the AMA Current Procedural Terminology edition of CPT becomes available in mid-November and
(CPT). In addition, levels of anesthesia and sedation may effective January 1 of the following year. Bi-annual code
be defined in individual state board regulations. changes to ICD-9-CM implemented by the government
The codes utilized in this paper are from CPT 2013 and used to take effect October 1 and April 1 and were valid
CDT 2013. through the following September 30. However, with the
implementation date for ICD-10-CM approaching, the
This paper will provide general guidelines only. Because government has placed a freeze on ICD-9-CM code chang-
significant variations may exist between regions, states and es. Thus, reporting a current procedure or diagnosis using
individual carriers, there is no single rule that uniformly a previous year’s edition may be inaccurate and adversely
governs this unique service. Ultimately, how anesthesia affect reimbursement or lead to unnecessary delays in
services provided by the surgeon are coded and billed claims processing.
depends on each individual carrier.
Familiarity and compliance with the other AAOMS coding CODING FOR ANESTHESIA SERVICES
papers, particularly those related to ICD-9-CM diagnostic USING CPT CODES
coding and procedural coding guidelines utilizing CPT, Under both medical (CPT) and dental (CDT) coding, the
HCPCS and CDT are necessary to utilize these codes use of local anesthesia is considered an inherent compo-
properly. nent of any surgical procedure, and is not billable sepa-
Participation in AAOMS Coding courses will provide rately.
valuable information to facilitate the correct use of the Moderate (Conscious) Sedation
codes.
Six CPT codes (99143, 99144, 99145, 99148, 99149 and
REQUIRED CODING MATERIALS 99150) were introduced in CPT 2006 for reporting “mod-
Before attempting to code any claims for services, it is erate (conscious) sedation” and two codes were eliminated
necessary to have a current copy of the American Dental (99141 and 99142). The ASA and CPT define Moderate
Association’s CDT, the American Medical Association’s Sedation /Analgesia as a drug-induced depression of
CPT, and the two-volume set of ICD-9-CM. Volumes 1 consciousness during which patients respond purposeful-
and 2 of the ICD-9-CM cover diagnostic coding which is ly to verbal commands, either alone or accompanied by
mandatory in filing claims to medical third party payers light tactile stimulation. No interventions are required to
and Medicare. Volume 1 represents a tabular listing of maintain a patent airway and spontaneous ventilation is
conditions, diseases, and symptoms; while volume 2 is the adequate. Cardiovascular function is usually maintained.
alphabetical listing. Volume 3 of the ICD-9-CM is only These codes are:
for hospitals, and is not necessary for the OMS office. 99143 Moderate sedation services (other than those ser-
CDT 2013 went into effect January 1, 2013 and is the most vices described by codes 00100-01999) provided
recent edition. It supersedes all previous CDT manuals and by the same physician or other qualified health
care professional performing the diagnostic or
therapeutic service that the sedation supports,
PAGE 1 Coding for Anesthesia Services
 Coding Paper
requiring the presence of an independent trained
observer to assist in the monitoring of the
patient’s level of consciousness and physiolog-
ical status; younger than 5 years of age, first 30
minutes intra-service time
99144 age 5 years or older, first 30 minutes intra-
service time
Some insurance companies will permit surgeons to re-
+ 99145 each additional 15 minutes intra-service port their anesthesia services by utilizing codes from the
time (List separately in addition to code for Anesthesia chapter of the CPT Manual. Such anesthesia
primary service); note that this is an add-on services are reported by the use of the anesthesia five digit
code and must be used in conjunction with procedure code plus the addition of a physical status mod-
99143, 99144 ifier. CPT codes 00100 through 00352 are the anesthesia
99148 Moderate sedation services (other than those ser- codes for the head and neck region. Unless advised other-
vices described by codes 00100-01999), provid- wise by a carrier, these codes are intended to be reported
ed by a physician or qualified health care pro- by a provider administering anesthesia for the operating
fessional other than the health care professional surgeon, or overseeing a CRNA. In either case, these codes
performing the diagnostic or therapeutic service are not generally used to report operator administered
that sedation supports; younger than 5 years of anesthesia.
age, first 30 minutes intra-service time The surgeon may be able to bill for supply of the anesthet-
99149 age 5 years or older, first 30 minutes intra- ic agent, as well as possibly for IV antibiotics, analgesics
service time and anti-inflammatory agents. The CPT supply code is
99070. Some insurance companies may prefer the appro-
+ 99150 each additional 15 minutes intra-service priate HCPCS Level II code representing the drugs admin-
time (List separately in addition to code for istered (J codes).
primary service); note that this is an add-on
Anesthesia Relative Values
code and must be used in conjunction with
99148, 99149 According to the American Society of Anesthesiologists
(ASA) Relative Value Guide, a “Basic Value” is assigned
In CPT 2013 there are many codes that have a “bulls-
to the anesthetic management of most surgical procedures.
eye” designation 8 in front of the code. These codes have
This “Basic Value” includes “all usual anesthesia ser-
moderate (conscious) sedation by the surgeon included in
vices,” except for the time actually spent in anesthesia care
the RVUs for that code. None of these codes are currently
and any modifiers. “Usual anesthesia services” includes
utilized by the OMS.
usual pre- and post-operative visits, administration of flu-
Deep Sedation / General Anesthesia ids and/or blood products incident to anesthesia care, and
the interpretation of noninvasive monitoring (e.g., ECG,
To report general anesthesia/deep sedation provided
temperature, blood pressure, oximetry, capnography).
by the surgeon performing the surgical procedure, it is
When more than one surgical procedure is performed
necessary to add modifier “-47” to the surgical procedure
during a single anesthetic, the “Basic Value” would be that
code. Modifier “-47” is not used as a modifier for the
of the procedure which has the highest unit value.
CPT Anesthesia Codes (00100 - 00352 for head and neck
procedures) as these reflect anesthesia services provided In addition to the ”Basic Value,” additional modifiers are
by an individual other than the operating surgeon. (Note: used to accurately code and bill for services. These modi-
The five digit modifier format was eliminated from CPT fiers are primarily the “Modifying Units” [see below] and
beginning in 2003 making the previous 09947 obsolete). “Time Units.” Other modifiers exist, but have little or no
For example, closed reduction of a mandibular fracture relevance to practicing OMS’s.
performed in the office under deep sedation / general anes- Physical Status Modifiers
thesia would be reported as: 21451 for the procedure, with
Physical Status Modifiers should be appended to any CPT
21451-47 as a separate line item for the anesthesia.
anesthesia chapter code. They are indicated with the initial

PAGE 2 Coding for Anesthesia Services

letter “P” followed by a single digit from 1-6 as listed
below:
P1 -
P2 -
Normal healthy patient.
Patient with mild systemic disease.
Coding Paper
P3 - Patient with severe systemic disease.
P4 - Patient with severe systemic disease that is a
of anesthesia (typically when the intravenous access is
constant threat to life.
established) and ends when he/she is no longer in personal
P5 - Moribund patient, not expected to survive with- attendance (i.e., when the patient is safely placed under
out the operation. postoperative supervision). This is expressed as “Time
P6 - Declared brain-dead patient whose organs are Units.” The basic “Time Unit” is generally considered to
being removed for donor purposes. be 15 minutes. However, carriers may vary in how they
define “Time Unit.” For example, 10 minutes could be
These six levels are consistent with the ASA classification considered the basic unit for some carriers. Be sure to ver-
of physical status and are added to the basic anesthesia ify with specific carriers how they define such time units,
code in the same fashion as any CPT modifier. (Example: and how they would like time reported. The HIPAA Elec-
00190 - P2) tronic Transaction Standard 5010 no longer accepts units,
Qualifying Circumstances and requires the reporting of total anesthesia time. The
total time is coded on the claim form under the column
Though technically not modifiers, these codes serve to
for “Units.” The official instructions for completing the
describe anesthesia services under unusual or difficult
CMS 1500 are maintained by the National Uniform Claim
circumstances. Such unusual circumstances and services
Committee (NUCC). The most recent instructions provide
may qualify for additional reimbursement when reported
guidance on reporting time above the date field in box 24
in addition to the anesthesia code. These codes are not
of the claim form. For a visual example, visit nucc.org and
reported alone, but in addition to the qualifying anesthesia
download the most current instructions.
procedure or service. More than one CPT code may be
used. WHAT ABOUT MEDICARE?
+99100 Anesthesia for patient of extreme age, under one Under Medicare, deep sedation/general anesthesia is
year or over 70. covered only for Medicare-covered procedures, and only if
+99116 Anesthesia complicated by utilization of total administered by another doctor or nurse anesthetist under
body hypothermia. the supervision of another doctor. Medicare presently
bundles the payment for deep sedation/general anesthesia
+99135 Anesthesia complicated by utilization of con- administered by or under the supervision of the operating
trolled hypotension. surgeon.
+99140 Anesthesia complicated by emergency condi- Thus, general anesthesia/deep sedation by surgeon is
tions (specify). non-covered and non-billable for Medicare covered
[Emergency is defined as existing when delay in treatment services. If, however, anesthesia is billed by a separate in-
would lead to a significant increase in the threat to life or dividual for a Medicare-covered service, time should be re-
body part.] ported in accordance with policies of your local Medicare
Administrative Contractor and the current instructions set
Reporting Time
forth by the National Uniform Claim Committee available
The other factor to consider when billing for anesthesia at http://www.nucc.org.
services is time. Anesthesia time begins when the anes-
Moderate sedation by the surgeon, on the other hand, is
thesia provider begins to prepare the patient for induction
carrier priced. This allows individual Medicare Part B
carriers discretion regarding approval and payment rates.

PAGE 3 Coding for Anesthesia Services

 Coding Paper
DENTAL CODING FOR ANESTHESIA
Under both medical (CPT) and dental (CDT) coding,
the use of local anesthesia is considered an inherent
component of any surgical procedure, and is not billable
separately.
Significant differences exist between anesthesia billing un-
der CPT and CDT. Notable among these are the absence
USING DENTAL CODES ON MEDICAL CLAIMS
of modifiers and the “Time Unit” concept. CDT does not
distinguish between operator administered anesthesia and In general, CPT codes are not used on ADA forms and
that provided by another practitioner. The concepts of CDT codes are not used on CMS 1500 (Medical) forms.
facility, supplies and materials are also inherently different However, some medical carriers may direct that you use
in dental and medical billing. It is important to keep these CDT codes on a CMS 1500 form for “dental” procedures
differences in mind when coding. which do not have an applicable CPT code (e.g. third
molars). In those situations, they may also request use of
When submitting anesthesia charges to a dental insurance
CDT anesthesia codes.
carrier, the following CDT 2013 codes should be used:
The presence of an anesthesia code, or any procedure code,
D9220 deep sedation/general anesthesia - first 30
does not guarantee payment for these services. It is crucial
minutes
for the OMS practitioner and his/her staff to understand
D9221 deep sedation/general anesthesia - each the intricacies of reimbursement for anesthesia services by
additional 15 minutes each carrier, managed care organization and Medicare.
D9230 analgesia, anxiolysis, inhalation of nitrous oxide Note: This paper should not be used as the sole reference in coding.
Both diagnosis and treatment codes change frequently, and insurance
D9241 intravenous conscious sedation/analgesia – first carriers may differ in their interpretations of the codes.
30 minutes
Coding and billing decisions are personal choices to be made by in-
D9242 intravenous conscious sedation/analgesia – each dividual oral and maxillofacial surgeons exercising their own profes-
additional 15 minutes sional judgment in each situation. The information provided to you in
this paper is intended for educational purposes only. In no event shall
D9248 non-intravenous conscious sedation AAOMS be liable for any decision made or action taken or not taken
by you or anyone else in reliance on the information contained in this
DEFINING START AND STOP TIME article. For practice, financial, accounting, legal or other professional
advice, you need to consult your own professional advisers.
As noted, anesthesia start time commences when the anes-
thesia provider initiates the appropriate anesthesia protocol
and remains in continuous attendance of the patient. An- This is one in a series of AAOMS papers designed to provide
information on coding claims for oral and maxillofacial surgery
esthesia time ends when the anesthesia provider can safely
(OMS). This paper discusses coding for anesthesia. This paper
leave the patient under postoperative supervision. Thus, is to aid the oral and maxillofacial surgeon with proper diagnosis
anesthesia services and time are considered completed (ICD-9-CM) and treatment (CPT/CDT) coding for anesthesia.
when the patient may be safely left under the observation When indicated, you will be referred to the appropriate area of
of a trained anesthesia assistant, and the doctor may safely the coding books where the principles of coding illustrated in this
leave the room to attend to other duties. paper may be applied.
Proper coding provides a uniform language to describe medical,
Additional CDT anesthesia codes exist, but do not apply
surgical, and dental services. Diagnostic and procedure codes
to anesthesia utilized in conjunction with a procedure. are continually updated or revised. The AAOMS Committee on
These codes are: Health Care and Advocacy has developed these coding guide-
lines in order to assist the membership to use the coding systems
D9210 local anesthesia not in conjunction with operative
effectively and efficiently.
or surgical procedures
D9211 regional block anesthesia
© 2013 American Association of Oral and Maxillofacial Surgeons.
D9212 trigeminal division block anesthesia No portion of this publication may be used or reproduced without
the express written consent of the American Association of Oral
D9215 local anesthesia in conjunction with operative or and Maxillofacial Surgeons.
surgical procedures Revised March 2013

PAGE 4 Coding for Anesthesia Services