How To Use CPT Code 00402

cpt 00402 describes anesthesia services for procedures on the integumentary system on the extremities, anterior trunk, and perineum, including reconstructive procedures on the breast. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and examples of cpt 00402.

1. What is cpt 00402?

cpt 00402 is a code used to describe anesthesia services provided by a healthcare professional during procedures on the integumentary system. These procedures can include surgeries on the extremities, anterior trunk, perineum, and reconstructive procedures on the breast. The anesthesia provider evaluates the patient before the procedure, administers anesthesia during the surgery, and monitors the patient’s vital signs and responses throughout the procedure.

2. Official Description

The official description of cpt 00402 is: ‘Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; reconstructive procedures on breast (eg, reduction or augmentation mammoplasty, muscle flaps)’

3. Procedure

The anesthesia provider performs a pre-operative evaluation of the patient before the procedure. They then induce anesthesia and monitor the patient’s vital signs and responses during the surgery. The anesthesia provider administers medications as necessary and uses various monitoring techniques such as ECG, temperature, blood pressure, oximetry, capnography, and mass spectrometry. After the procedure, the anesthesia provider oversees the patient’s transfer to the post-anesthesia care unit.

4. Qualifying circumstances

cpt 00402 is used for anesthesia services during procedures on the integumentary system, including reconstructive procedures on the breast. The patient must undergo a surgery on the extremities, anterior trunk, perineum, or breast that requires anesthesia. The anesthesia provider must evaluate the patient before the procedure and administer anesthesia during the surgery. The anesthesia services may include the use of standard monitoring techniques, but unusual forms of monitoring may be separately coded if documented appropriately.

5. When to use cpt code 00402

cpt 00402 should be used when a patient undergoes a procedure on the integumentary system, such as surgeries on the extremities, anterior trunk, perineum, or reconstructive procedures on the breast. The anesthesia provider must be present during the procedure, administering anesthesia and monitoring the patient’s vital signs and responses. This code should be used for each procedure that requires anesthesia.

6. Documentation requirements

To support a claim for cpt 00402, the anesthesia provider must document the following information:

• Patient’s pre-operative evaluation
• Start and stop times of anesthesia care
• Types and amounts of medications administered
• Monitoring techniques used during the procedure
• Patient’s responses and vital signs during the procedure
• Any additional procedures or interventions performed
• Transfer of the patient to the post-anesthesia care unit

7. Billing guidelines

When billing for cpt 00402, ensure that the anesthesia provider is qualified to administer anesthesia and is present during the procedure. Use the appropriate modifiers, such as AA, AD, QK, QY, GC, QX, and QZ, as required by the payer. If multiple anesthesia services are provided during the same encounter, report the most complex anesthesia procedure code with the highest base unit value. The total anesthesia time should be documented and reported in the appropriate field on the claim form.

8. Historical information

cpt 00402 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 00402

Five similar codes to cpt 00402 include:

• cpt 00400: Anesthesia for procedures on the thorax (chest wall and shoulder girdle)
• cpt 00401: Anesthesia for procedures on the thorax (chest wall and shoulder girdle); not otherwise specified
• cpt 00403: Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; not otherwise specified
• cpt 00404: Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; not otherwise specified; not otherwise specified
• cpt 00405: Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; not otherwise specified; not otherwise specified; not otherwise specified

9. Examples

1. An anesthesia provider administering anesthesia during a breast reduction surgery.
2. An anesthesia provider monitoring a patient’s vital signs during a procedure on the extremities.
3. An anesthesia provider administering anesthesia during a reconstructive procedure on the perineum.
4. An anesthesia provider evaluating a patient before a breast augmentation surgery.
5. An anesthesia provider monitoring a patient’s responses during a reconstructive procedure on the anterior trunk.
6. An anesthesia provider administering anesthesia during a procedure on the extremities and monitoring the patient’s oxygen levels using oximetry.
7. An anesthesia provider overseeing a patient’s transfer to the post-anesthesia care unit after a breast reconstruction surgery.
8. An anesthesia provider documenting the start and stop times of anesthesia care during a procedure on the perineum.
9. An anesthesia provider administering medications during a reconstructive procedure on the anterior trunk.
10. An anesthesia provider using capnography to measure the concentration of carbon dioxide in a patient’s exhaled breath during a procedure on the extremities.