Sample page. Anesthesia. Cross Coder. Essential links from CPT codes to ICD-10-CM and HCPCS

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1 Cross Coder 2018 Anesthesia Essential links from CPT codes to ICD-10-CM and HCPCS POWER UP YOUR CODING with Optum360, your trusted coding partner for 32 years. Visit optum360coding.com.

2 Contents Introduction...i CPT Anesthesia to Procedure Code Crosswalk... i Format... i Icon Key... ii CPT Codes... ii Physicians and Other Qualified Health Care Professionals... ii Code Links... iii ICD-10-CM Diagnostic Codes... iii HCPCS Level II Codes... iii Modifiers... iv Summary... iv CPT Procedure to Anesthesia Code...1 Head...39 Neck Thorax (Chest Wall and Shoulder Girdle) Intrathoracic Spine and Spinal Cord Upper Abdomen Lower Abdomen Perineum Pelvis (Except Hip) Upper Leg (Except Knee) Knee and Popliteal Area Lower Leg (Below Knee, Includes Ankle and Foot) Shoulder and Axilla Upper Arm and Elbow Forearm, Wrist, and Hand Radiological Procedures Burn Excisions or Debridement Obstetric Other Procedures Introduction/Injection of Anesthetic Agent (Nerve Block) Diagnostic or Therapeutic Moderate (Conscious) Sedation Appendix: Modifiers for Use with Anesthesia Services Optum360, LLC 2016 American Medical Association. All Rights Reserved. i

3 Introduction Optum360 is pleased to present the 2017 Anesthesia Cross Coder. Fully comprehensive, the Anesthesia Cross Coder links more than 300 CPT codes commonly used by anesthesiologists to corresponding surgical CPT and ICD-10-CM diagnosis codes, and as appropriate, ICD-10-CM procedure and HCPCS Level II codes. Optum360 believes that professional coders working in physician offices, clinical outpatient areas, hospitals, as well as payer settings will find this reference a useful tool. Anesthesia Cross Coder is based on the Anesthesia section of Physicians Current Procedural Terminology (CPT), but includes CPT codes commonly used by practicing anesthesiologists from other sections of the CPT system as well. Up-to-date CPT codes link to the following related medical coding systems: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) Healthcare Common Procedure Coding System (HCPCS) Level II All coding relationships in Anesthesia Cross Coder start with the Anesthesia section of the CPT book presenting a general clinical picture of each anesthesia code. Pertinent surgical related coding relationships were carefully reviewed and screened for appropriate information. In some instances, the data is abridged simply due to the enormity of the listings. For example, diagnosis codes for infections call for additional codes to identify specific organisms. The possible associations are too numerous and do not appear in Anesthesia Cross Coder. For further discussion, see the ICD-10-CM section later in this introduction. Some CPT codes are omitted from the listing because consistent and reliable cross-links are almost impossible to establish. Unlisted procedure codes are an obvious example. As a coding reference, Anesthesia Cross Coder presents most likely scenarios as derived from clinical information and official sources. Anesthesia Cross Coder is not a substitute for ICD-10-CM or any other medical coding reference and users are urged to regularly consult all available sources. The absence of any specific code does not necessarily indicate that its association to the base procedure code is inappropriate. Assuming all rules of anesthesia coding are followed, excepted diagnosis codes may prove appropriate to a specific code scenario. Anesthesia Cross Coder does not include coding rules or guidelines. Once again, the user is urged to consult the original coding reference (e.g., CPT, ICD-10-CM, HCPCS Level II, etc.) or one of several reputable medical coding instruction manuals. CPT Anesthesia to Procedure Code Crosswalk The surgical CPT codes are listed with the corresponding anesthesia CPT codes. The relationships were developed by comparing each individual surgical CPT code, current practice patterns, and techniques to determine the appropriate relationship of the surgical code to the anesthesia CPT code assignment. Using this methodology, the surgical codes and anesthesia codes are assigned the most appropriate coding relationships. Optum360 does not rely on the combinations suggested by other organizations or groups with the exception of CMS. Reimbursement data was not used to suggest one code combination over another. Format An understanding of the Anesthesia Cross Coder format allows users to easily navigate its content. Information within the main section ties to the CPT book and the codes are presented in the same numeric order as the anesthesia and other appropriate CPT sections. Sections Anesthesia Cross Coder provides linked information to the CPT code range to 01999, as well as several other code ranges typically used by anesthesiologists. The codes are divided into the same sections as found in the CPT book. Codes and Code Ranges The data within each CPT code set of Anesthesia Cross Coder is presented as follows: Anesthesia CPT code Corresponding surgical CPT codes and descriptions ICD-10-CM diagnostic codes and descriptions HCPCS Level II codes and descriptions, where applicable For example: Anesthesia for procedures involving plastic repair of cleft lip Associated CPT Codes Plastic repair of cleft lip/nasal deformity; primary, partial or complete, unilateral Plastic repair of cleft lip/nasal deformity; primary bilateral, 1-stage procedure Plastic repair of cleft lip/nasal deformity; primary bilateral, 1 of 2 stages Plastic repair of cleft lip/nasal deformity; secondary, by recreation of defect and reclosure Plastic repair of cleft lip/nasal deformity; with cross lip pedicle flap (Abbe-Estlander type), including sectioning and inserting of pedicle ICD-10-CM Diagnostic Q36.0 Cleft lip, bilateral Q36.1 Cleft lip, median Q36.9 Cleft lip, unilateral Q37.0 Cleft hard palate with bilateral cleft lip Q37.1 Cleft hard palate with unilateral cleft lip Q37.2 Cleft soft palate with bilateral cleft lip Q37.3 Cleft soft palate with unilateral cleft lip Q37.4 Cleft hard and soft palate with bilateral cleft lip Q37.5 Cleft hard and soft palate with unilateral cleft lip Q37.8 Unspecified cleft palate with bilateral cleft lip 2 Q37.9 Unspecified cleft palate with unilateral cleft lip 2 Z42.8 Encounter for other plastic and reconstructive surgery following medical procedure or healed injury 2016 Optum360, LLC 2016 American Medical Association. All Rights Reserved. i

4 CPT Procedure to Anesthesia Code 0051T 0052T 0053T 0071T 0072T 0075T T T T 0191T 0195T 0200T 0201T 0202T 0219T T T 0234T 0235T 0236T 0237T T T 0253T 0254T 0255T 0263T T T 0267T 0268T 0269T 0270T 0271T 0274T 0275T 0293T 0294T 0299T T 0303T 0304T 0307T 0308T T T T T 0316T 0335T T T T T 0356T 0375T T 0395T 0398T 0402T 0404T T T T 0409T 0410T 0411T 0412T 0413T T T T 0419T 0420T 0421T T 0425T 0426T 0427T 0428T 0429T 0430T 0431T 0432T 0433T 0446T 0447T 0448T 0449T 0451T 0452T 0453T 0454T 0455T 0456T 0457T 0458T 0459T 0460T 0461T 0465T T 0468T Optum360, LLC CPT 2016 American Medical Association. All Rights Reserved.

5 Lower Abdomen Anesthesia for procedures on lower anterior abdominal wall; not otherwise specified Associated CPT Codes Placement of soft tissue localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous, including imaging guidance; first lesion Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection; abdominal wall, with or without fascial closure Free fascial flap with microvascular anastomosis Graft; derma-fat-fascia Exploration of penetrating wound (separate procedure); abdomen/flank/back Injection of sinus tract; therapeutic (separate procedure) Injection of sinus tract; diagnostic (sinogram) Removal of foreign body in muscle or tendon sheath; simple Removal of foreign body in muscle or tendon sheath; deep or complicated Placement of needles or catheters into muscle and/or soft tissue for subsequent interstitial radioelement application (at the time of or subsequent to the procedure) Excision, tumor, soft tissue of abdominal wall, subfascial (eg, intramuscular); less than 5 cm Excision, tumor, soft tissue of abdominal wall, subfascial (eg, intramuscular); 5 cm or greater Excision, tumor, soft tissue of abdominal wall, subcutaneous; less than 3 cm Excision, tumor, soft tissue of abdominal wall, subcutaneous; 3 cm or greater Radical resection of tumor (eg, sarcoma), soft tissue of abdominal wall; less than 5 cm Radical resection of tumor (eg, sarcoma), soft tissue of abdominal wall; 5 cm or greater Revision of ileostomy; simple (release of superficial scar) (separate procedure) Revision of colostomy; simple (release of superficial scar) (separate procedure) Abdominal paracentesis (diagnostic or therapeutic); without imaging guidance Abdominal paracentesis (diagnostic or therapeutic); with imaging guidance Peritoneal lavage, including imaging guidance, when performed Biopsy, abdominal or retroperitoneal mass, percutaneous needle Sclerotherapy of a fluid collection (eg, lymphocele, cyst, or seroma), percutaneous, including contrast injection(s), sclerosant injection(s), diagnostic study, imaging guidance (eg, ultrasound, fluoroscopy) and radiological supervision and interpretation when performed Injection of air or contrast into peritoneal cavity (separate procedure) Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), percutaneous, intra-abdominal, intra-pelvic (except prostate), and/or retroperitoneum, single or multiple Removal of tunneled intraperitoneal catheter Exchange of previously placed abscess or cyst drainage catheter under radiological guidance (separate procedure) Contrast injection for assessment of abscess or cyst via previously placed drainage catheter or tube (separate procedure) Insertion of cecostomy or other colonic tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report Replacement of gastrostomy or cecostomy (or other colonic) tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report Injection procedure for visualization of ileal conduit and/or ureteropyelography, exclusive of radiologic service Aspiration of bladder; by needle Aspiration of bladder; by trocar or intracatheter Aspiration of bladder; with insertion of suprapubic catheter Change of cystostomy tube; simple Change of cystostomy tube; complicated Transabdominal amnioinfusion, including ultrasound guidance ; Fetal umbilical cord occlusion, including ultrasound guidance ; Fetal fluid drainage (eg, vesicocentesis, thoracocentesis, paracentesis), including ultrasound guidance ; Fetal shunt placement, including ultrasound guidance ; Replacement or revision of cerebrospinal fluid shunt, obstructed valve, or distal catheter in shunt system ICD-10-CM Diagnostic Codes C47.4 C49.4 C49.8 C76.2 C79.89 D17.39 D18.03 D19.1 D19.7 D20.1 D48.4 E E E E G04.1 G71.0 G71.2 G71.3 G71.8 G72.49 G72.81 G72.89 G73.7 G83.4 K65.0 K65.1 K65.2 K65.3 K65.8 K66.1 K66.8 K67 K68.11 K68.12 K68.19 K68.9 K94.01 K94.02 K94.03 K94.09 Malignant neoplasm of peripheral nerves of abdomen Malignant neoplasm of connective and soft tissue of abdomen Malignant neoplasm of overlapping sites of connective and soft tissue Malignant neoplasm of abdomen Secondary malignant neoplasm of other specified sites Benign lipomatous neoplasm of skin and subcutaneous tissue of other sites Hemangioma of intra-abdominal structures Benign neoplasm of mesothelial tissue of peritoneum Benign neoplasm of mesothelial tissue of other sites Benign neoplasm of soft tissue of peritoneum Neoplasm of uncertain behavior of peritoneum Diabetes mellitus due to underlying condition with other skin ulcer Drug or chemical induced diabetes mellitus with other skin ulcer Drug or chemical induced diabetes mellitus with other skin complications Other specified diabetes mellitus with other skin ulcer Tropical spastic paraplegia Muscular dystrophy Congenital myopathies Mitochondrial myopathy, not elsewhere classified Other primary disorders of muscles Other inflammatory and immune myopathies, not elsewhere classified Critical illness myopathy Other specified myopathies Myopathy in diseases classified elsewhere Cauda equina syndrome Generalized (acute) peritonitis Peritoneal abscess Spontaneous bacterial peritonitis Choleperitonitis Other peritonitis Hemoperitoneum Other specified disorders of peritoneum Disorders of peritoneum in infectious diseases classified elsewhere Postprocedural retroperitoneal abscess Psoas muscle abscess Other retroperitoneal abscess Other disorders of retroperitoneum Colostomy hemorrhage Colostomy infection Colostomy malfunction Other complications of colostomy 2016 Optum360, LLC CPT 2016 American Medical Association. All Rights Reserved. ; Female diagnosis : Male diagnosis 273