Coding Tips

Question: While using active warming, the patient’s body temperature measurement was equal to or greater than 96.8 degrees Fahrenheit.  The temperature was taken within the designated timeframe for a general anesthesia case that lasted 47 minutes.  Should I report G9363 only?

 

Answer: Yes, you can use code G9363 (Duration of monitored anesthesia care [MAC] or peripheral nerve block [PNB] without the use of general anesthesia during an applicable procedure or general or neuraxial anesthesia less than 60 minutes, as documented in the anesthesia record).

 

Refresher: This code applies for all patients, regardless of age, undergoing surgical or therapeutic procedures under general or neuraxial anesthesia of 60 minutes duration or longer, except patients undergoing cardiopulmonary bypass.

 

Other codes are for patients who meet one of two criteria:

 

*   Active warming was used intraoperatively for the purpose of maintaining normothermia;

or

*  At least one body temperature equal to or greater than 36 degrees Centigrade (or 96.8 degrees Fahrenheit) was recorded within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time.

 

The anesthesia time used for this measure should be the time recorded in the anesthesia record.