Health data standards and systems

The distinction between sedation and general anaesthesia is often unclear from clinical documentation. For the purposes of classification in ACHI, 92515-XX [1910] Sedation may be assigned where the anaesthetic is administered as per general anaesthesia (ie intravenous or inhalational or both) and there is no documentation of the use of an artificial airway, such as an endotracheal tube, laryngeal mask or Guedel airway.

I, and other coders, read this part of the standard as 2 statements of fact. The first sentence says that the distinction is often unclear. It then goes on to say for the purposes of classification if there is no artificial airway a code for sedation may be assigned.

Others coders report their view that if the anaesthetist ticks a box stating GA, then, even in the absence of documentation of an artificial airway, a GA should be coded, as the documentation is clear.

Even though the anaesthetist might consider he/she has administered a GA without the use of an artificial airway, my interpretation, based on the second sentence, is that the artificial airway is the determining factor in deciding the code.

Could this please be clarified? If a GA box is ticked but there is no artificial airway documented, can the committee please suggest that this is made clear in a future edition or errata?

The VICC notes that point 2 under the heading Cerebral anaesthesia in ACS 0031 Anaesthesia should be read in the context of point 1. Coding Matters Volume 15 Number 3 article titled Anaesthestic coding confirms that where documentation is unclear as to the type of anaesthetic being administered follow the guidelines in ACS 0031 Anaesthesia. In cases where the general anaesthetic box is ticked, the documentation is clear and therefore a code for general anaesthetic can be assigned.