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|