How To Use CPT Code 01938

cpt 01938 describes the anesthesia services provided by a healthcare professional during percutaneous image-guided injection, drainage, or aspiration procedures on the lumbar or sacral spine or spinal cord. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and examples of cpt 01938.

1. What is cpt 01938?

cpt 01938 is used to describe the anesthesia services provided by a healthcare professional during percutaneous image-guided injection, drainage, or aspiration procedures on the lumbar or sacral spine or spinal cord. This code is specifically for procedures performed on the lower back region containing vertebrae L1 through L5 or the area containing the sacrum, the triangular bone at the base of the spine, just above the tailbone (coccyx).

2. Official Description

The official description of cpt 01938 is: ‘Anesthesia for percutaneous image-guided injection, drainage or aspiration procedures on the spine or spinal cord; lumbar or sacral.’

3. Procedure

The anesthesia provider performs a pre-operative evaluation of the patient. They then induce the patient and monitor them during the percutaneous image-guided injection, drainage, or aspiration procedures on the lumbar or sacral spine or spinal cord that a different provider performs. The anesthesia provider notes the types and amounts of medications administered, all forms of monitoring used, patient responses, and the start and stop times of anesthesia care. After the procedure, the anesthesia provider oversees the patient’s transfer to post-anesthesia care.

4. Qualifying circumstances

cpt 01938 is used for anesthesia services during percutaneous image-guided injection, drainage, or aspiration procedures on the lumbar or sacral spine or spinal cord. It is important to note that this code is specifically for procedures performed on the lower back region or the area containing the sacrum. The anesthesia provider must perform a pre-operative evaluation of the patient and be present during the procedure to monitor the patient’s vital signs and administer any necessary medications.

5. When to use cpt code 01938

cpt 01938 should be used when a healthcare professional provides anesthesia services during percutaneous image-guided injection, drainage, or aspiration procedures on the lumbar or sacral spine or spinal cord. This code is specific to procedures performed on the lower back region or the area containing the sacrum. It is important to ensure that the anesthesia provider performs a pre-operative evaluation of the patient and is present during the procedure to monitor the patient’s vital signs and administer any necessary medications.

6. Documentation requirements

To support a claim for cpt 01938, the anesthesia provider must document the following information:

• Pre-operative evaluation of the patient
• 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 01938, ensure that the anesthesia provider performs a pre-operative evaluation of the patient and is present during the percutaneous image-guided injection, drainage, or aspiration procedures on the lumbar or sacral spine or spinal cord. It is important to follow the specific guidelines and requirements of the payer when submitting the claim. If there are any additional procedures or services performed during the same encounter, assign the most complex anesthesia procedure code with the highest base unit value. Append the appropriate HCPCS modifiers to the anesthesia code as required by the payer.

8. Historical information

cpt 01938 was added to the Current Procedural Terminology system on January 1, 2022. There have been no updates to the code since its addition.

9. Examples

1. An anesthesia provider administering anesthesia during a percutaneous image-guided injection procedure on the lumbar spine.
2. An anesthesia provider monitoring a patient during a percutaneous image-guided drainage procedure on the sacral spine.
3. An anesthesia provider administering anesthesia during a percutaneous image-guided aspiration procedure on the lumbar spine.
4. An anesthesia provider monitoring a patient during a percutaneous image-guided injection procedure on the sacral spine.
5. An anesthesia provider administering anesthesia during a percutaneous image-guided drainage procedure on the lumbar spine.
6. An anesthesia provider monitoring a patient during a percutaneous image-guided aspiration procedure on the sacral spine.
7. An anesthesia provider administering anesthesia during a percutaneous image-guided injection procedure on the spinal cord.
8. An anesthesia provider monitoring a patient during a percutaneous image-guided drainage procedure on the spinal cord.
9. An anesthesia provider administering anesthesia during a percutaneous image-guided aspiration procedure on the spinal cord.
10. An anesthesia provider monitoring a patient during a percutaneous image-guided injection procedure on the lumbar and sacral spine.