How To Use CPT Code 99116

CPT 99116 describes the utilization of total body hypothermia during anesthesia, which complicates the administration of anesthesia. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes and billing examples.

1. What is CPT Code 99116?

CPT 99116 can be used to describe the utilization of total body hypothermia during anesthesia, which affects the complexity of the anesthesia service. This code is used when the provider induces hypothermia in the patient during a procedure, complicating the administration of anesthesia.

2. Official Description

The official description of CPT code 99116 is: ‘Anesthesia complicated by utilization of total body hypothermia (List separately in addition to code for primary anesthesia procedure).’ This code is an add-on code and should only be reported along with a primary anesthesia procedure code.

3. Procedure

1. During a procedure in which anesthesia is administered, the provider induces total body hypothermia in the patient.
2. The induction of hypothermia complicates the administration of anesthesia and affects the complexity of the anesthesia service.
3. The provider must document the induction of the hypothermic state at the time of providing the anesthesia service to support the use of this code.

4. Qualifying circumstances

CPT 99116 is used when the provider induces total body hypothermia during a procedure, complicating the administration of anesthesia. This is most commonly done during intracranial surgeries. The provider must document the induction of the hypothermic state at the time of providing the anesthesia service to support the use of this code.

5. When to use CPT code 99116

CPT code 99116 should be used when the provider induces total body hypothermia during a procedure, complicating the administration of anesthesia. It should only be reported along with a primary anesthesia procedure code. However, it should not be reported if the primary anesthesia code already includes hypothermia in its base.

6. Documentation requirements

To support a claim for CPT 99116, the provider must document the induction of total body hypothermia during the procedure. Examples of documentation include: hypothermic state induced, surgeon’s request for hypothermia initiated, or temperature reduced to 34.5 degrees C per surgeon request.

7. Billing guidelines

When billing for CPT 99116, ensure that it is reported along with an appropriate primary anesthesia code. Payers will not reimburse for this add-on code if it is reported without a primary anesthesia code. It is important to note that many heart procedures already include hypothermia in the base anesthesia code, so CPT 99116 should not be reported in those cases.

8. Historical information

CPT 99116 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates to the code since its addition.

9. Examples

1. A patient undergoing intracranial surgery requires anesthesia. The provider induces total body hypothermia during the procedure, complicating the administration of anesthesia.
2. During a surgical procedure, the provider induces hypothermia in the patient as per the surgeon’s request. This affects the complexity of the anesthesia service.
3. A patient undergoing a complex procedure requires anesthesia. The provider reduces the patient’s temperature to 34.5 degrees C as per the surgeon’s request, complicating the administration of anesthesia.
4. During a procedure, the provider induces total body hypothermia in the patient, affecting the complexity of the anesthesia service. The hypothermic state is documented in the patient’s medical record.
5. A patient undergoing intracranial surgery requires anesthesia. The provider initiates hypothermia as per the surgeon’s request, complicating the administration of anesthesia.
6. During a surgical procedure, the provider induces total body hypothermia in the patient, affecting the complexity of the anesthesia service. The induction of hypothermia is documented in the patient’s medical record.
7. A patient undergoing a complex procedure requires anesthesia. The provider induces hypothermia in the patient, as per the surgeon’s request, complicating the administration of anesthesia.
8. During a procedure, the provider reduces the patient’s temperature to 34.5 degrees C, as per the surgeon’s request. This affects the complexity of the anesthesia service.
9. A patient undergoing intracranial surgery requires anesthesia. The provider initiates total body hypothermia, complicating the administration of anesthesia.
10. During a surgical procedure, the provider induces hypothermia in the patient, affecting the complexity of the anesthesia service. The induction of hypothermia is documented in the patient’s medical record.