How To Use CPT Code 00216

cpt 00216 describes anesthesia services for intracranial vascular procedures. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and examples of cpt 00216.

1. What is cpt 00216?

cpt 00216 is a code used to describe anesthesia services provided by a healthcare professional during intracranial vascular procedures. These procedures involve the blood vessels inside the skull. The anesthesia provider performs a pre-operative evaluation of the patient, induces anesthesia, monitors the patient during the procedure, and oversees the patient’s transfer to post-anesthesia care. The anesthesia services include the administration of medications, fluid management, and standard monitoring such as ECG, temperature, blood pressure, oximetry, capnography, and mass spectrometry.

2. Official Description

The official description of cpt 00216 is: ‘Anesthesia for intracranial procedures; vascular procedures.’

3. Procedure

The anesthesia provider begins by performing a pre-operative evaluation of the patient. This evaluation helps determine the appropriate anesthesia plan for the intracranial vascular procedure. During the procedure, the anesthesia provider administers anesthesia to induce and maintain the patient’s unconsciousness and pain control. They closely monitor the patient’s vital signs, administer medications as needed, and ensure the patient’s safety and comfort throughout the procedure. After the procedure, the anesthesia provider oversees the patient’s transfer to the post-anesthesia care unit.

4. Qualifying circumstances

cpt 00216 is used for anesthesia services provided during intracranial vascular procedures. These procedures involve the blood vessels inside the skull. The anesthesia provider must document the types and amounts of medications administered, all forms of monitoring used, patient responses, and the start and stop times of anesthesia care. Unusual forms of monitoring, such as the use of Swan-Ganz catheters, intra-arterial lines, or central venous lines, may be coded separately if sufficient supporting documentation is available.

5. When to use cpt code 00216

cpt 00216 should be used when anesthesia services are provided for intracranial vascular procedures. It is important to ensure that the anesthesia provider’s time associated with the patient’s care starts when the anesthesia provider prepares the patient for anesthesia induction in the operating room or procedure room. The anesthesia provider’s time ends when they no longer render services to the patient or when another provider assumes responsibility for the patient’s postoperative care.

6. Documentation requirements

To support a claim for cpt 00216, the anesthesia provider must document the following information:

• Patient’s pre-operative evaluation
• Types and amounts of medications administered
• Forms of monitoring used
• Patient responses
• Start and stop times of anesthesia care
• Transfer of the patient to post-anesthesia care

7. Billing guidelines

When billing for cpt 00216, ensure that the anesthesia provider’s documentation supports the anesthesia services provided during intracranial vascular procedures. Anesthesia time should be calculated based on the time the anesthesia provider spends with the patient, starting from the preparation for anesthesia induction. The total anesthesia time should be reported in block 24G of the CMS 1500 form. If multiple anesthesia services are provided for the same patient during the same encounter, report the most complex anesthesia procedure code with the highest base unit value. Qualifying circumstances codes may be assigned for complex anesthesia cases.

8. Historical information

cpt 00216 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates to the code since its addition.

9. Similar codes to cpt 00216

Five similar codes to cpt 00216 include:

• cpt 00210: Anesthesia for intracranial procedures; not otherwise specified
• cpt 00212: Anesthesia for intracranial procedures; other than cranial nerve
• cpt 00214: Anesthesia for intracranial procedures; cranial nerve
• cpt 00218: Anesthesia for intracranial procedures; other than cranial nerve or carotid artery
• cpt 00222: Anesthesia for intracranial procedures; carotid artery

9. Examples

1. An anesthesia provider administering anesthesia for a patient undergoing an intracranial vascular procedure to treat an aneurysm.
2. An anesthesia provider monitoring a patient’s vital signs and administering anesthesia during an intracranial vascular procedure to remove a brain tumor.
3. An anesthesia provider ensuring the patient’s comfort and pain control during an intracranial vascular procedure to repair a cerebral arteriovenous malformation.
4. An anesthesia provider managing the patient’s anesthesia and monitoring their vital signs during an intracranial vascular procedure to treat a cerebral aneurysm.
5. An anesthesia provider administering anesthesia and monitoring the patient’s oxygen levels during an intracranial vascular procedure to treat a stroke.
6. An anesthesia provider overseeing the patient’s transfer to the post-anesthesia care unit after an intracranial vascular procedure to repair a cerebral aneurysm.
7. An anesthesia provider documenting the types and amounts of medications administered during an intracranial vascular procedure to treat a brain arteriovenous malformation.
8. An anesthesia provider monitoring the patient’s blood pressure and heart rate during an intracranial vascular procedure to remove a blood clot in the brain.
9. An anesthesia provider ensuring the patient’s safety and comfort during an intracranial vascular procedure to treat a cerebral arteriovenous fistula.
10. An anesthesia provider documenting the start and stop times of anesthesia care during an intracranial vascular procedure to repair a cerebral aneurysm.