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Anesthesia Billing for Gyn Procedures

Cathy Posted Mon 09th of September, 2019 15:06:20 PM
Our office performs operative hysteroscopy (CPT 58558) and Treatment of missed abortion (CPT 59820), providing IV general anesthesia and following up with monitored anesthesia care (MAC) during recovery. How would I go about billing for the anesthesia provided?
SuperCoder Answered Tue 10th of September, 2019 06:38:43 AM

For Hysteroscopy procedure (58558) you can use anesthesia code 00952 {Anesthesia for vaginal procedures (including biopsy of labia, vagina, cervix or endometrium); hysteroscopy and/or hysterosalpingography} and for Treatment of missed abortion (59820) anesthesia code 01965 (Anesthesia for incomplete or missed abortion procedures) can be used. As per CCI edits, there is no bundling in both the codes (58558 & 59820), but make sure to provide the necessity of both the procedures when performed on same date of service and by same physician.

On the other hand, if the procedures are performed in different session and/or different date of service, then both the procedures can be billed.

Monitored anesthesia care includes all aspects of anesthesia care, a pre-procedure visit, intra-procedure care and post-procedure anesthesia management.

During monitored anesthesia care, the anesthesiologist provides or medically directs a number of specific services, including but not limited to:

  • Diagnosis and treatment of clinical problems that occur during the procedure
  • Support of vital functions
  • Administration of sedatives, analgesics, hypnotics, anesthetic agents or other medications as necessary for patient safety
  • Psychological support and physical comfort
  • Provision of other medical services as needed to complete the procedure safely.

Since, you have performed the procedure under general anesthesia, which includes post-procedure anesthesia care/management, then you cannot bill it separately for the MAC under recovery.

Still, if there is need of procedure under recovery, then MAC code will depend on the type of procedure performed.

Also, there must be medical necessity to perform the procedure and you need to prove it by providing the strong documentation.

Hope this helps!

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