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2025 CPT code 00212

Anesthesia for intracranial procedures; subdural taps.

Anesthesia time is calculated from when the anesthesiologist begins preparing the patient in the operating room until they are no longer responsible for the patient's care. Standard monitoring services are included; unusual forms (e.g., Swan-Ganz catheters) are coded separately. When multiple anesthesia services are performed during the same encounter, use the most complex code and combine anesthesia times.

Modifiers can be used to indicate specific circumstances, such as unusual anesthesia (23), discontinued procedures (53), repeat procedures (76, 77), or physical status modifiers (P1-P6). HCPCS modifiers are used for Medicare and other payers to specify the type of anesthesia services rendered (e.g., AA, AD, QK, QS). These provide important details about the anesthesia and can influence the reimbursement amount or eligibility for specific payments. For example, it may indicate medical direction of CRNA service by a physician or an anesthesiologist "opt out" physician or practitioner emergency or urgent service.

Medical necessity for 00212 is established when a subdural tap is deemed medically necessary to diagnose or treat a condition causing excess fluid and pressure around the brain. The documentation should clearly support the need for the procedure.

The anesthesiologist is responsible for the patient's well-being throughout the subdural tap procedure. This includes pre-operative assessment, administering anesthesia, monitoring vital signs, managing any complications, and providing post-anesthesia care. They document all medications, monitoring techniques, patient responses, and anesthesia times.

In simple words: The anesthesiologist provides all the care needed to keep you comfortable and safe during a procedure to remove excess fluid from around your brain. This includes checking you before the procedure, giving you medicine to make you sleep and not feel pain, and carefully watching you during and after the procedure.

This code represents anesthesia services provided during intracranial subdural taps. A subdural tap is a procedure where fluid is removed from the subdural space, the area between the outer and middle membrane layers covering the brain. This is often done to relieve pressure on the brain caused by excess fluid. The anesthesia services include pre-operative evaluation, inducing anesthesia, monitoring the patient throughout the procedure, administering medications, managing fluids/blood, and post-anesthesia care.

Example 1: A 6-month-old infant presents with an enlarged head circumference and suspected subdural hematoma. Code 00212 is used for the anesthesia services provided during the subdural tap performed to diagnose the condition and relieve pressure., An adult patient requires a subdural tap following a head injury to drain excess fluid. Code 00212 would be reported for the anesthesia services provided during this procedure., A patient with a chronic subdural hematoma requires repeated subdural taps to manage their condition. 00212 is used for each instance of anesthesia provided for these taps.

Documentation should include a pre-anesthesia evaluation, details of the anesthesia administered, monitoring techniques used (e.g., ECG, blood pressure, oximetry), patient response, start and end times of anesthesia, fluids/blood administered, and any complications encountered.

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