Question

Report the appropriate anesthesia code(s) for a patient who had general anesthesia for a total shoulder replacement. At the surgeon's request, the anesthesiologist placed a brachial plexus continuous catheter for postoperative pain management. The day after surgery, the patient was seen by the anesthesiologist for follow-up care. What are the correct codes for this encounter?

A.01630, 64416-59, 01996
B.01638, 64415-59
C.01638, 64415-59, 01996
D.01638, 64416-59

Answer 1

The correct anesthesia codes for a patient who had general anesthesia for a shoulder replacement, with a brachial plexus catheter for pain and a follow-up, are 01630, 64416-59, and 01996.

Step-by-step explanation:

The correct anesthesia codes for a patient who had general anesthesia for a total shoulder replacement and subsequently had a brachial plexus continuous catheter placed for postoperative pain management, followed by a follow-up visit the day after surgery, are 01630, 64416-59, and 01996. This reflects the initial anesthesia service (01630), the additional separate procedure of placing the pain management catheter (64416-59; modifier 59 indicates a distinct procedural service), and the postoperative pain management follow-up on the subsequent day (01996).

During general anesthesia, it is important to maintain an open airway due to the relaxation of muscles necessary for breathing and moving the tongue—this is often achieved with endotracheal intubation. The anesthesiologist plays a key role in gradually changing the mixture of gases that keep the patient unconscious, and upon regaining muscle function, the intubation tube is removed. Recovery from anesthesia continues as the patient regains muscle control necessary for respiration, and commonly a sore or scratchy throat is experienced post-surgery.