AAPC - Chapter 16 Practical
Applications
CASE 1
CRNA performed anesthesia (Use Modifier QX to indicate CRNA services with medical
direction by a physician.)
Anesthesiologist medically directing two cases (Use modifi
...
AAPC - Chapter 16 Practical
Applications
CASE 1
CRNA performed anesthesia (Use Modifier QX to indicate CRNA services with medical
direction by a physician.)
Anesthesiologist medically directing two cases (Use modifier QK to indicate medical direction
of two cases.)
Anesthesia Time: 9:30 to 10:06
Physical Status 3 (Physical status 3 - use P3 modifier.)
PREOPERATIVE DIAGNOSIS: Cyst on knee
POSTOPERATIVE DIAGNOSIS: Baker's Cyst (Use post-operative diagnosis.)
PROCEDURE: Excision of Baker's Cyst, knee (Excision is an open procedure and is performed
on the knee.)
ANESTHESIA: Monitored Anesthesia Care (MAC services require QS modifier.)
What are the CPT® and ICD-10-CM Codes reported for the Anesthesiologist?
What are the CPT® and ICD-10-CM Codes reported for the CRNA?
What is the time reported for this service? - ✔✔00140-QK-QS-P3
M71.20
001400-QX-QS-P3
M71.20
36
CASE 2
Anesthesiologist personally performed (Personally performed by anesthesiologist—use AA
modifier.)
Anesthesia Time: 7:12 to 10:08 (Time is 176 minutes.)
Physical Status 2 (Physical status 2, use P2 modifier.)
PREOPERATIVE DIAGNOSIS: Suspected Prostate Cancer
POSTOPERATIVE DIAGNOSIS: Prostate Carcinoma (Post-operative diagnosis.)
PROCEDURE: Radical Retropubic Prostatectomy (Procedure performed. Make note the
procedure is "radical.")
ANESTHESIA: General (General anesthesia.)
What are the CPT® and ICD-10-CM Codes reported for the Anesthesiologist?
CPT® code(s): [a]
ICD-10-CM code(s): [b]
What is the time reported for this service? - ✔✔00865-AA-P2
C61
176
CASE 3
Non-medically directed CRNA (CRNA services without medical direction require modifier QZ.)
performed anesthesia care and documented intra-operative placement of continuous femoral
nerve catheter for post operative pain. (Anesthesia and intraoperative placement of continuous
femoral nerve catheter.)
Anesthesia Time: 7:18 to 9:10 (Time calculates to 1 hour 52 minutes, or 112 minutes.)
Physical Status 3 (Physical status 3 requires P3 modifier.)
PREOPERATIVE DIAGNOSIS: Left Knee Osteoarthritis
POSTOPERATIVE DIAGNOSIS: Left Knee Osteoarthritis, localized primary, (Primary
diagnosis is specified as Left Knee Osteoarthritis, localized, primary.) Acute post-operative pain
(Diagnosis of Acute post-operative pain gives medical necessity for the intra-operative
placement of continuous femoral nerve catheter.)
PROCEDURE: Total Knee Arthroplasty (The procedure is total knee arthroplasty NOT
Arthroscopy, which carries a lower base value.)
ANESTHESIA: General anesthesia (Anesthesia provided is general.) provided for surgery,
Surgeon requested post-operative pain management via continuous femoral catheter
What are the CPT® and ICD-10-CM Codes reported for the CRNA?
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