Preoperative assessment is included in the payment for the anesthesia services, per the National Correct Coding Initiative (NCCI).
HCPCS/CPT® codes include all services usually performed as part of the procedure as a standard of medical/surgical practice. A physician should not separately report these services simply because HCPCS/CPT® codes exist for them.
1. The anesthesia care package consists of preoperative evaluation, standard preparation and monitoring services, administration of anesthesia, and post- anesthesia recovery care.
Preoperative evaluation includes a sufficient history and physical examination so that the risk of adverse reactions can be minimized, alternative approaches to anesthesia planned, and all questions answered.
2. Anesthesia services include, but are not limited to, preoperative evaluation of the patient, administration of anesthetic, other medications, blood, and fluids, monitoring of physiological parameters, and other supportive services.
3. It is standard medical practice for an anesthesia practitioner to perform a patient examination and evaluation prior to surgery. This is considered part of the anesthesia service and is included in the base unit of the anesthesia code.
The evaluation and examination are not reported in the anesthesia time. If surgery is canceled, subsequent to the preoperative evaluation, payment may be allowed to the anesthesiologist for an evaluation and management service and the appropriate E&M code (usually a consultation code) may be reported. (A non-medically directed CRNA may also report an E&M code under these circumstances if permitted by state law.)