ADDITIONAL DOCUMENTATION |
CABG (33510-33516, 33533-33536) |
| 00567 - ON pump (CABG, but if procedure includes valve work report 00562) |
| 00562 - ON pump (Valve procedures OR CABG re-operation 1 month after original) |
| 00566 - OFF pump (Heart is not placed on a pump) |
Cardiac Valves (33361-33496) |
| 00560- OFF pump |
| 00561- ON pump, younger than 1 year of age |
| 00562 - ON pump, age 1 year or older |
| 00563 - ON pump with hypothermic circulatory arrest |
| Lung/Thoracotomy Procedures (Many codes in 32_ series) |
| 00528 - Mediastinoscopy and diagnostic thoracoscopy not utilizing 1 lung vent |
| 00529 - Mediastinoscopy and diagnostic thoracoscopy utilizing 1 lung vent |
| 00541 and 00626 - Surgical procedure, One Lung Vent Anesthesia |
| 00625 - thoracic spine and cord, via an anterior transthoracic approach not utilizing 1 lung vent |
| 00540 - Two Lung Anesthesia |
| Spinal Arthrodesis (22532-22633) |
| 00620- Thoracic spine and cord procedure |
| 00630- Lumbar spine and cord procedure |
| 00600- Cervical spine and cord |
| 00670- Extensive spine and spinal cord procedures |
| Spinal Instrumentation (22808-22812) |
| 00670 - Extensive spine, spinal cord procedures (spinal instrumentation, vascular) |
| 00625 - Thoracic spine and cord, via anterior transthoracic approach, not using one lung vent |
| 00626 - Thoracic spine and cord, via anterior transthoracic approach, utilizing one lung vent |
| Knee Scopes (29870 vs 29866-29867, 29871-29887) |
| 01400 - Surgical/Specificity of Surgery |
| 01382 - Diagnostic/No Specificity of Surgery (code 29870 only) |
| Shoulder Scopes (29805 vs 29806-29828) |
| 01630 - Surgical/Specificity of Surgery |
| 01622 - Diagnostic/No Specificity of Surgery (code 29805 only) |
| Elbow Scopes (29830 vs 29834-29838) |
| 01740 - Surgical/Specificity of Surgery |
| 01732 - Diagnostic/No Specificity of Surgery (code 29830 only) |
| Abdominal Procedures |
| 00790 - Upper Abdominal Procedures |
| 00840 - Lower Abdominal Procedures |
| ASA instruction for intestinal procedures states to use 00840 when work is exclusively on the sigmoid or rectum. |
| Intracranial Procedures (Craniectomies, etc) |
| 00218 - Intracranial procedures in sitting position |
| 00216 - Intracranial procedures; vascular procedures |
| 00211 - Intracranial procedures; craniotomy or craniectomy for evacuation of hematoma |
| 00210 - Intracranial procedures; not otherwise specified |
| Integumentary/Skin Procedures (some codes from 10000 series) |
| 00400 - Procedures on integumentary system of extremities, anterior trunk and perineum |
| 00300 - Procedures on integumentary system, muscles and nerves of head, neck and posterior trunk |
| Cysto procedures (ureteroscopy for lithotripsy or for ureter tumor/lesion) |
| 00910 - Transurethral procedures; not otherwise specified |
| 00918 - Transurethral procedures; fragmentation, manipulation and/or removal of ureteral calculus |
| Anesthesia for Pain Injections (62320-62327, 64400-64530-excluding facets) |
| 01991 - Other than prone position |
| 01992 - Prone position |
| 01935 - Percutaneous image guided procedures on the spine and spinal cord;diagnostic |
| 01936 - Therapeutic |
| Biopsy, prostate; (55700-55706) |
| 00400 - Biopsy with no mention of an anorectal approach |
| 00902 - Biopsy involving an anorectal approach |
| 00910 - Biopsy involving a transurethral approach |
| Incision and drainage of abscess (e.g. carbuncle, supporative hidradentis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single (10060) |
| 00400 - I & D procedure of extremities, anterior trunk and perineum |
| 00300 - I & D procedure of head, neck and posterior trunk |
| Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.5 cm or less (11400) |
| 00400 - Excision procedure of extremities, anterior trunk and perineum |
| 00300 - Excision procedure of head, neck and posterior trunk |
| Removal of implant, deep (leg, buried wire, pin, screw, metal band, nail, rod or plate) (20680) |
| 01360 - Removal of implant involving lower one-third of femur |
| 00170 - Removal of implant intraoral |
| 00190 - Removal of implant on facial bones or skull |
| 00450 - Removal of implant on clavicle and scapula |
| 00470 - Removal of implant for rib |
| 01170 - Removal of implant symphysis pubis or sacroliliac joint |
| 01210 - Removal of implant hip joint |
| 01392 - Removal of implant upper ends of tibia, fibula, and/or patella |
| 01630 - Removal of implant humeral head and neck, sternoclavicular joint, acrominoclavicular joint, and shoulder joint |
| 01740 - Removal of implant elbow |
| 01480 - Removal of implant involving the lower leg, ankle or foot |
| 01830 - Removal of implant involving distal radius, ulna, wrist or hand |
| 01230 - Removal of implant involving upper two-thirds of femur |
| 01400 - Removal of implant involving the knee joint |
| Debridement, skin, subcutaneous tissue and muscle (11043) |
| 00300 - Debridement involving muscles and nerves of head, neck and posterior trunk. NOS |
| 01250 - Debridement involving upper leg |
| 01320 - Debridement involving knee and/or popliteal |
| 01470 - Debridement involving the lower leg, ankle or foot |
| 01610 - Debridement involving shoulder and axilla |
| 01710 - Debridement involving upper arm and elbow |
| 01810 - Debridement involving the forearm, wrist or hand muscles |
| Craniectomy for excision of brain tumor, infrastentorial or posterior fossa; except meningioma, cerebellopontine angle tumor, or midline tumor at base of skull (61518) |
| 00210 - Excision with no mention of sitting position |
| 00218 - Excision involving a patient in the sitting position |
| Removal of lung, other than total pneumonectomy, single lobe (lobectomy) (32480) |
| 00540 - Removal with no mention of one lung ventilation anesthesia |
| 00541 - Removal involving one lung ventilation anesthesia technique |
| Enterolysis (freeing of intestinal adhesion) (44005) |
| 00840 - Involving only the lower abdomen |
| 00790 - Involving the upper abdomen |
| Excision, tumor, soft tissue of neck or thorax, subcutaneous (21552, 21554, 21555-21558) |
| 00300 - Excision procedure on head, neck or posterior trunk |
| 00400 - Excision procedure on extremities, anterior trunk or perineum or patient in a prone position |
| 00320 - Procedures on esophagus, thyroid, larynx, trachea and lymphatic system of neck ( applies as choice for procedures 21557 &21558 only) |
| CYSTOURETHROSCOPY (52000-52315) |
| 00910 - Transurethral procedures (including urethrocystoscopy) |
| 00918 - Transurethral procedures with fragmentation, manipulation and/or removal ureteral calculus |
| 00916- Post-transurethral resection bleeding (applies as choice for procedure 52001only) |
| 00912- Transurethral procedures with resection of bladder tumor(s) (applies as choice for procedures 52234-52240 only) |
| LITHOTRIPSY (50590) |
| 00873 Without water bath |
| 00872 With water bath |
| BIOPSY MUSCLE (20200-20206) |
| 00300 - Integumentary system, muscles and nerves of head, neck and posterior trunk |
| 01250 - Upper leg |
| 01320 - Knee and/or popliteal |
| 01470 - Lower leg, ankle and foot |
| 01610 - Shoulder and axilla |
| 01710 - Upper arm and elbow |
| 01810 - Forearm, wrist and hand |
| EXPLORATION FOR POSTOPERATIVE HEMORRHAGE, THROMBOSIS OR INFECTION; EXTREMITY (35860) |
| 01770 - Arteries of upper arm and elbow |
| 01270 - Arteries of upper leg |
| 01440 - Arteries of knee and popliteal area |
| 01500 - Arteries of lower leg |
| 01840 - Arteries of forearm, wrist, hand |
| 01844 - Vascular shunt, or shunt revision, any type (eg, dialysis) |
| LIGATION, DIVISION, AND/OR EXCISION OF VARICOSE VEIN CLUSTERS (37785) |
| 01260 - Veins of upper leg |
| 01430 - Veins of knee and popliteal |
| 01520 - Veins on lower leg |
| BIOPSY OR EXCISION OF LYMPH NODE(S) (38500-38530) Documentation needs to include indication whether the procedure was performed superficial or deep. |
| 01610 - Shoulder and axilla |
| 00320 - Lymphatic system of neck |
| 00400 - Extremities, anterior trunk and perineum |
| 00540- Thoracotomy procedures involving lungs, plueura, diphragm and mediastinum, not utilizing one lung ventilation (applies as choice for 38530 procedure only) |
| 00541- Thoracotomy procedures involving lungs, pluera, diaphragm and medistinum utilizing one lung ventilation (applies as choice for 38530 choice only) |
| BREAST MASS REMOVAL 19301 VS 19302 |
| 00400 - Lumpectomy (19301) |
| 01610 - with axillary sentinel node biopsy (19302) |
| EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF FEMUR (27355-27356) |
| 01230 - Anesthesia for open procedures involving upper two-thirds of femur; not otherwise specified |
| 01360 - Anesthesia for all open procedures on lower one-third of femur |
| ATRIAL OR VENTRICULAR LEAD REVISION (pacemaker vs cardioverter-defibrillator) |
| 00530 - Anesthesia for permanent transvenous pacemaker insertion |
| 00534 - Anesthesia for transvenous insertion or replacement of pacing cardioverter-defibrillator |
| HIP PROCEDURES |
| 01210 - Anesthesia for open procedures involving hip joint |
| 01214 - Anesthesia for open procedures involving hip joint; total hip arthroplasty |
| 01215 - Anesthesia for open proceddures involving hip jont; revision of total hip arthroplasty |
| FEMORAL FRACTURE |
| 01230 - Anesthesia for open procedures involving upper two-thirds of femur |
| 01360 - Anesthesia for open procedures involving lower one-third of femur |
| HUMERAL FRACTURE |
| 01744 - Open treatment of humeral shaft fracture with plate/screws, with or without cerclage |
| 01740 - Open treatment of humeral condylar, epicondylar, supracondylar or transcondylar fracture |
| AICD OR PACEMAKER: (skin pocket vs generator plcmnt vs lead plcmnt vs system plcmnt) |
| 00400 - Anesthesia for integumentary system procs on the extremities, anterior trunk & perineum |
| 00530 - Anesthesia for permanent transvenous pacemaker insertion |
| 00534 - Anesthesia for transvenous insertion or replacement of pacing cardioverter-defibrillator |
| OOCYTE RETRIEVAL (58970) |
| 00940 - Anesthesia for vaginal removal |
| 00840 - Anesthesia for intraperitoneal removal |
| TEE |
| Probe Placement only for diagnostics - 93313 Probe Placement for monitoring purposes 93318 |
| Diagnostic with Probe Placement, image acquisition, interpretation, and report - 93312 |
| Transcatheter intracardiac or great vessel(s) structural intervention(s) I.C. - 93355 |
| Use the approved medical neccessity diagnosis. |
| Epidurals & Blocks: MUST be indicated as post-op pain (when not used as the primary mode of anesthesia) and "requested per surgeon" to be billed separately. |
| Ultrasound/Flouroscopic guidance: Documentation MUST indicate the image being saved/stored on file AND include a report indicating the purpose of the ultrasound/flouroscopic guidance to be billed separately. |
| Field Avoidance: any procedure with limited airway access increases billing to minimum. |
| Patient Position (other than Supine and Lithotomy) may impact the ASA code assigned resulting in increased base units for some procedures |
| RLD - Right Lateral Decubitus (Face Up) |
| LLD - Left Lateral Decubitus (Face Up) |
| Prone / Jacknife - (Face Down) |
| Sitting (Beach Chair) / Fowler |
| Trendelenberg |
| Emergency: If delay in treatment = threat to life or body part. |
| Physical Status: determined by systemic diseases a patient may have: |
| P1 - normal healthy person |
| P2 - mild systemic disease |
| P3 - severe systemic disease |
| P4 - severe systemic disease that is a constant threat to life |
| P5 - moribund patient who is not expected to survive without the operation |
| P6 - declared brain-dead patient whose organs are being removed for donor purposes |
| Controlled Hypotension = additional (do not report in addition to ASA code 00561, 00562, 00563, or 00567) |
| Total Body Hypothermia = additional (do not report in addition to ASA code 00561, 00562, 00563, or 00567) |
