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2025 CPT code 00921

Anesthesia for procedures on male genitalia (including open urethral procedures); vasectomy, unilateral or bilateral.

Use appropriate modifiers to indicate the level of medical direction provided by the anesthesiologist, especially when CRNAs are involved (e.g., QX, QY, QZ). Physical status modifiers (P1-P6) are assigned by the anesthesiologist to reflect the patient's health status.

Modifiers are applicable and may be required to specify the type of anesthesia, level of medical direction, or unusual circumstances. Some applicable modifiers are: 23 - Unusual Anesthesia AA - Anesthesia services performed personally by anesthesiologist AD - Medical supervision by a physician: more than four concurrent anesthesia procedures QK - Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals QS - Monitored anesthesia care service QX - CRNA service: with medical direction by a physician QY - Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist QZ - CRNA service: without medical direction by a physician Modifiers P1-P6 are used to describe the patient's physical health status.

Medical necessity is established by the underlying procedure performed on the male genitalia. The chosen type of anesthesia should be appropriate for the patient's condition and the complexity of the procedure.

The anesthesiologist performs a pre-operative evaluation, administers anesthesia, monitors the patient's vital signs throughout the procedure, manages fluids/blood administration, and oversees post-anesthesia recovery. The anesthesiologist also documents the types and amounts of medication used, monitoring methods, patient responses, and anesthesia start/stop times.

In simple words: This code covers the anesthesia provided during a vasectomy or other procedures involving the male reproductive organs. The anesthesiologist monitors the patient's vital signs and comfort levels throughout the procedure.

This code represents anesthesia services provided for procedures on the male genitalia, including vasectomy (unilateral or bilateral) and open urethral procedures. The anesthesia services encompass pre- and post-operative evaluation, inducing the patient, monitoring vital signs during the procedure (including ECG, temperature, blood pressure, oximetry, and capnography), administering fluids/blood, and overseeing the patient's transfer to post-anesthesia care. Unusual forms of monitoring (e.g., Swan-Ganz catheters) are not included and can be coded separately.

Example 1: A patient undergoes a bilateral vasectomy under local anesthesia administered by an anesthesiologist., A patient with high anxiety receives monitored anesthesia care (MAC) during an open urethral procedure., A patient requires general anesthesia for a complex procedure involving the male genitalia due to a pre-existing medical condition.

Documentation should include pre- and post-operative evaluations, type and amount of anesthesia administered, monitoring techniques employed, patient responses, start and stop times of anesthesia, and any complications encountered.

** Anesthesia time is calculated from the time the anesthesiologist prepares the patient in the operating room until another qualified healthcare provider assumes responsibility for post-operative care. When billing for multiple anesthesia services during the same encounter, the most complex procedure code with the highest base unit value is billed, and anesthesia times are combined.

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