55 yrs old patient, a lipoma is removed from his chest wall measuring 6sg cm and the defect is 9sq cm requiring an intermediate closure. MAC is performed by a medically directed CRNA (Certified registered nurse anesthetist). How would you report the anesthesia service?



Answer :

To report the anesthesia service for the scenario described, you would use the appropriate CPT (Current Procedural Terminology) code for the anesthesia provided during the intermediate closure of the chest wall following the removal of a lipoma. Here's how you would typically report it:

1. Use CPT code 00400 for anesthesia for procedures on the integumentary system on the chest wall (not otherwise specified).

2. Since the anesthesia was performed by a CRNA who was medically directed, you should use the modifier QX (CRNA service: with medical direction by a physician).

3. If applicable, use a physical status modifier to describe the condition of the patient (e.g., P1 for a normal healthy patient, P2 for a patient with mild systemic disease, etc.).

4. The patient's age does not require a separate modifier but is considered in the context of the case.

So, the coding would look like this:

00400-QX-P1 (assuming the patient is a normal healthy patient).

00400: Anesthesia for procedures on the integumentary system of the chest wall.

QX: CRNA service with medical direction by a physician.

P1: Normal healthy patient (if applicable, modify this based on the patient's physical status).

Ensure that all relevant documentation supports the use of these codes and modifiers. Additionally, if there are any specific local or payer requirements, those should be taken into consideration.

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