Question: What information should be documented on the anesthesia record if controlled hypotension (99135) is used?
Answer: Qualifying circumstances are unique to anesthesia coding and identify certain patient conditions, operative conditions or other special risk factors. Documentation must support an induced hypotensive state.
We would expect to see the following phrases on the record:
– “Hypotensive state induced”
– “Surgeon’s request for hypotension initiated”
– “Blood pressure reduced to 80/50 per surgeon request”
You should not use the patient’s charted blood pressure alone when assigning code 99135 because it is intended to be used only when hypotension is induced deliberately, not just an incidental condition.