Count on This Coding Guide to Ace Unusual ‘Anesthesia by Surgeon’ Scenarios

Fri, Feb 27, 2015 --

Reader Questions

Discover whether modifier 47 will break surgery/anesthesia bundles.

Anesthesia is an essential part of a successful surgery, but knowing how to code when a physician performs both the anesthesia and the surgery can be tough.

Our coding experts have handpicked two unusual “anesthesia by surgeon” scenarios that some of the most experienced coders found difficult to code. These solutions will help you understand both proper coding and which services to expect payment for.

Scenario 1: A patient came in for a scheduled endometrial biopsy (58558), but she became agitated before the anesthesiologist entered the room. The surgeon administered a regional block (64421) before performing the surgery. Which service(s) should you report for the surgeon?

Coding solution: This is an atypical situation. Payer guidelines vary, but you could append modifier 47 (Anesthesia by surgeon) to CPT® code 58558 (Hysteroscopy, surgical; with sampling [biopsy] of endometrium and/or polypectomy, with or without D & C) because the anesthesiologist was not present when the surgeon administered the regional block. For payers who accept modifier 47, you may also be able to report CPT® code 64421 (Injection, anesthetic agent; intercostal nerves, multiple, regional block) for the regional block.

Reality: Many payers, including Medicare, will not reimburse you for anesthesia the surgeon performs. Correct Coding Initiative (CCI) edits bundle 58558 and 64421, and you can’t use a modifier to override the edit because the edit has a modifier indicator of 0. It’s also worth noting that modifier 47 is not one of the modifiers you can use to override an edit.

Scenario 2The surgeon administers local anesthesia before placing a port for chemotherapy access in an adult patient. How should you code?

Coding solution: You will need more information to select the appropriate surgical code because there are several codes for insertion of a venous catheter. Ask your physician for the following details to identify the correct code for venous access procedures:

  • What is the age of the patient? (There are different codes for less than 5 years and 5 years or older.)
  • What type of a catheter did the physician insert? (Tunneled or non-tunneled?)
  • Where did the physician place the line? (Centrally or peripherally?)
  • Is there a port or pump?

Based on the complete documentation, select an appropriate code from the following range:

  • 36561, Insertion of tunneled centrally inserted central venous access device, with subcutaneous port; age 5 years or older
  • 36566, Insertion of tunneled centrally inserted central venous access device, requiring 2 catheters via 2 separate venous access sites; with subcutaneous port(s)
  • 36571,Insertion of peripherally inserted central venous access device, with subcutaneous port; age 5 years or older.

Bonus tip: Medicare considers l%3


Deborah concentrates on coding and compliance for radiology and cardiology, including the tricky world of interventional procedures, as well as oncology and hematology. Since joining The Coding Institute in 2004, she’s also covered the ins and outs of coding for orthopedics, audiology, skilled nursing facilities (SNFs), and more.

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