10/28/15 – Support Your Controlled Hypotension Claim


Question: What should we document on the anesthesia record for a case involving controlled hypotension?

Answer:  First, keep in mind that the anesthesia provider’s documentation must support an induced hypotensive state. The circumstances qualifying for this are unique to anesthesia coding and identify certain patient conditions, operative conditions, or other special risk factors that lead your provider to believe the patient needs to be in a hypotensive state during surgery.

The following phrases should be present in the record to support the use of 99135 (Anesthesia complicated by utilization of controlled hypotension.)

  • Hypotensive state induced
  • Surgeon’s request for hypotension initiated
  • Blood pressure reduced to 80/50 per surgeon request

Key note: Do not rely on the patient’s charted blood pressure alone when assigning 99135. Code 99135 is intended to be used only when hypotension is induced deliberately, not when it occurs as an incidental condition.

Remember too that 99135 is an add-on code, which means you must report it in conjunction with a primary procedure code.

Extra tip: Make sure you don’t report 99135 separately when the anesthesia code you’re reporting already includes the service of 99135 (such as 00561, Anesthesia for procedures on heart, pericardial sac, and great vessels of chest; with pump oxygenator, younger than 1 year of age).




New coding guidance: New notes in CPT 2016 answer injection questions, may drive payer policies

Published by DecisionHealth,, November 2015, by Julia Kyles, CPC-A


Don’t overlook the new guidance scattered throughout your CPT 2016 manual. This guidance can impact your coding and payments as much as the addition, revision or deletion of a code.

Next year’s CPT manual contains relatively few code changes that impact anesthesia and pain management practices. However, you should note guideline changes at the chapter and individual code level:

  • Same day E/M and preventive visits clarified. When a clinician provides an E/M and a preventive visit on the same day, append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the problem-focused E/M visit, states the guidance for counseling risk factor reduction and behavior change intervention codes 99401-99412. For example, 99213-25, 99408 (Alcohol and/or substance [other than tobacco] abuse structured screening [e.g., AUDIT, DAST], and brief intervention [SBI] services; 15 to 30 minutes).

Some payers won’t cover both visits on the same day, but the clarification may change that, says Maxine Lewis, CMM, CPC, CCS-P, owner, Medical Coding & Reimbursement, Cincinnati.


To ensure payment of both services, remind doctors to fully document both visits. For example, after a payer initially said it would not pay problem-focused visits on the same day as a preventive visit, Lewis was able to piece together elements of the clients’ documentation and show it met the requirements for both services. The payer agreed to cover 100% of the preventive visit and 50% of the problem-focused visit.


However, an outside auditor, such as a carrier conducting medical review, might not take the time to parse a note, so Lewis recommends that providers create distinct and separate notes for each visit.

  • Documentation required for bundled imaging. A new imaging services guideline in the Surgery chapter makes it clear that doctors must meet the documentation and reporting requirements for all imaging services. So doctors are still required to follow the rules for needle guidance when it is bundled into a pain management service. This is an area where doctors struggle even when they are paid, Lewis says.

Use the new guidance to drive home the need to document the service and how easy it is to document needle guidance. Here is an excerpt from a chart note that you can use as an example:


“A 27-gauge needle was used to infiltrate 5 mL of lidocaine subcutaneously, after which a 3.5-inch, 20-gauge Tuohy needle was advanced under direct fluoroscopic view and epidural space was identified using loss of resistance to air technique and negative aspiration for CSF and heme. 1 mL of Isovue-200 was injected, which confirmed excellent spread within the epidural space.”

  • Three revisions to paravertebral facet denervation. Code-level guidance for denervation codes 63633-63636 reminds you to count the joints, not the nerves, when reporting the injections. When you report a denervation that does not meet the definition of the code — such as pulsed frequency or low temperature — report unlisted code 64999. You should report 63633 when the provider destroys the nerves that innervate the T12-L1 facet joints.
  • Sacroiliac denervations explained. A note after 64636 instructs providers to report 64640 (Destruction by neurolytic agent; other peripheral nerve or branch) for “destruction by neurolytic agent, individual nerves, sacroiliac joint.” The update echoes guidance in the CPT Assistant, June 2012, which agreed with the use of 64640 to report “each individual peripheral neurolytic nerve destruction procedure performed at the L5, S1, S2, and S3 nerves.”



ICD-10 coding crosswalk: Headaches and other pains affecting the head

Published by DecisionHealth, October 2015



Get a handle on diagnosis codes for pain that affects the head and neck with this ICD-10-to-ICD-9 crosswalk that gives you a sampling of the codes for such conditions as migraine, ear ache and jaw pain. The illustration below shows the corresponding ICD-10 codes.


Some differences to note between ICD-9 and ICD-10 include easier migraine coding. Under ICD-9, you had to select a fifth character to indicate whether the migraine was intractable and whether the note mentioned status migrainosus. ICD-10 codes spell out the entire condition. In other cases, ICD-10 splits an unspecified headache code into for headaches that are and are not intractable.


Codes for pain of the ear and eye have been split into four codes each for left, right, bilateral or unspecified.


For past anatomical charts and crosswalks, see APCPS 12/13 for the spine from the occipital bone to level T12 and APCPS 9/15 for the spine from thoracolumbar to coccyx.


ICD-10 Codes ICD-9 Codes
G43.001 Migraine without aura, not intractable, with status migrainosus 346.12 Migraine without aura without mention of intractable migraine with status migrainosus
G43.009 Migraine without aura, not intractable, without status migrainosus 346.10 Migraine without aura without mention of intractable migraine without mention of status migrainosus
G43.101 Migraine with aura, not intractable, with status migrainosus 346.02 Migraine with aura without mention of intractable migraine with status migrainosus
G43.109 Migraine with aura, not intractable, without status migrainosus 346.00 Migraine with aura without mention of intractable migraine without mention of status migrainosus
G43.C0 Periodic headache syndromes in child or adult, not intractable 346.20 Variants of migraine not elsewhere classified, without mention of intractable migraine without mention of status migrainosus
G43.C1 Periodic headache syndromes in child or adult, intractable 346.21 Variants of migraine not elsewhere classified, with intractable migraine, so stated, without mention of status migrainosus
G44.001 Cluster headache syndrome, unspecified, intractable 339.00 Cluster headache syndrome, unspecified
G44.009 Cluster headache syndrome, unspecified, not intractable
G44.031 Episodic paroxysmal hemicrania, intractable 339.03 Episodic paroxysmal hemicrania
G44.039 Episodic paroxysmal hemicrania, not intractable
G44.221 Chronic tension-type headache, intractable 339.12 Chronic tension type headache
G44.229 Chronic tension-type headache, not intractable
G44.52 New daily persistent headache (NDPH) 339.42 New daily persistent headache
G44.53 Primary thunderclap headache 339.43 Primary thunderclap headache
G44.85 Primary stabbing headache 339.85 Primary stabbing headache
G50.0 Trigeminal neuralgia 350.1 Trigeminal neuralgia
G50.1 Atypical facial pain 350.2 Atypical facial pain
H57.10 Ocular pain, unspecified eye 379.91 Pain in or around eye
H57.11 Ocular pain, right eye
H57.12 Ocular pain, left eye
H57.13 Ocular pain, bilateral
H92.01 Otalgia, right ear 388.70 Otalgia, unspecified
H92.02 Otalgia, left ear
H92.03 Otalgia, bilateral
H92.09 Otalgia, unspecified ear
J34.89 Other specified disorders of nose and nasal sinuses 478.19 Other disease of nasal cavity and sinuses
K08.8 Other specified disorders of teeth and supporting structures 525.8 Other specified disorders of teeth and supporting structures
K13.79 Other lesions of oral mucosa 528.9 Other and unspecified diseases of the oral soft tissues
K14.6 Glossodynia 529.6 Glossodynia
M26.62 Arthralgia of temporomandibular joint 524.62 Temporomandibular joint disorders, arthralgia of temporomandibular joint
M54.2 Cervicalgia 723.1 Cervicalgia
N95.1 Menopausal and female climacteric states 627.2 Symptomatic menopausal or female climacteric states
R07.0 Pain in throat 784.1 Throat pain
R51 Headache 784.0 Headache
R68.84 Jaw pain 784.92 Jaw pain


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