The Role of Anesthesiologists in the COVID-19 Pandemic

In some clinical settings, the role of anesthesiologists is temporarily shifting with the current COVID-19 pandemic. Those changing roles are affecting everything from how anesthesiologists are keeping themselves safe during patient care to how they are coding and billing for their services.

During a recent online town hall meeting offered by the American Society of Anesthesiologists (ASA), Mary Dale Peterson, MD, the ASA president, along with a panel of experts from the Anesthesia Patient Safety Foundation (APSF) and several ASA committee members offered updates on practice standards for treating patients with COVID-19.

Personal Protective Equipment

One recommendation from the panel was for physicians to use N95 masks only with patients who are suspected of having COVID-19, and to use additional personal protective equipment (PPE), such as eye shields and surgical masks, to protect the providers and the N95 masks. However, since testing for COVID-19 has not been available either universally or promptly, making it impossible to identify all patients who are positive for COVID-19, the ASA, along with the Anesthesia Patient Safety Foundation (APSF), American Academy of Anesthesiologist Assistants (AAAA) and American Association of Nurse Anesthetists (AANA), have since updated those recommendation to include wearing N95 masks or similarly protective equipment, such as powered air-purifying respirators (PAPRs), in all diagnostic therapeutic and surgical procedures.

In the event PPE supplies become extremely limited, the panel recommended following the CDC guidelines for extended use and limited reuse of NIOSH-certified N95 filtering facepiece respirators.

Postpone Nonessential Surgeries

Another important recommendation from the panel was that nonessential surgeries be postponed to conserve ORs, PPE, hospital staff, and other resources for urgent COVID-19 cases. A similar call has been made by the CDC, President Trump, and many state governments.

From OR to ICU

With ORs sitting empty and many procedures postponed, some experts are calling for the transformation of ORs into intensive care units and anesthesiologists, among other clinicians, into intensivists to meet the need of critical COVID-19 patients. In a recent Anesthesiology News article, Adam Schlifke, MD, a member of the Stanford University clinical faculty, lays out a plan to Prepare for Overwhelmed ICUs by Leveraging Existing ORs, Anesthesia Machines and Peri-op Personnel.

“All U.S.-based hospital ORs and ambulatory surgery center (ASC) ORs have dedicated anesthesia machines which are capable for use as ventilators alone, and all the equipment that is necessary to keep critically-ill patients alive is in the OR,” Dr. Schlifke writes. “Furthermore and more importantly, the staff in the OR are exquisitely trained to care for critically ill patients, with many providing such care daily for surgical operations on critically ill patients. The anesthesiology care is commonly led by an anesthesiologist physician who may be working alone or with physician residents, certified registered nurse anesthetists and/or anesthesiology assistants, an anesthesia technologist, a circulating nurse, and surgical scrub technologist or a surgical nurse. This team has the skills, expertise, and knowledge to care for critically ill patients in the OR.”

Dr. Schlifke recommends the following steps for preparing for such a transformation:

Affected hospitals should rapidly identify & gather relevant stakeholders in the planning and implementation of proposed changes.
The OR Stakeholders (Charge Anesthesiologist, Charge Nurse and/or Perioperative Medical Director) and COO/Facilities Management should determine appropriate allocation of operating rooms.
Stakeholders should determine collaboratively the criteria for which patients to triage to the ORs for medical management.
The OR Charge Staff (Charge Nurse & Physician Anesthesiologist) will have to determine what sort of staffing ratio will be appropriate for the transferred critically-ill patients.
Facilities management and other staff need to ready those OR rooms by pacing signage in appropriate places that notes patient is a critically ill medical patient.
Once the above steps have been completed, a single point of contact from the ICU (Likely the Physician Intensivist) and a single point of contact from the OR (Likely the Physician Anesthesiologist) should coordinate the care of the patients being transported from the ER or ICU to the OR.

From Anesthesiologist to Intensivist

While not all ORs may be converted to ICU rooms, anesthesiologists still may be called on to perform more critical care services than usual, including procedures they usually perform on an occasional basis, such as arterial catheterization, central venous catheter placements, and intubations. As well, anesthesiologists may be asked to cover ventilation management or provide regular visits for patients admitted to the ICU.

Coding Considerations

The following CPT codes may be useful for coding the expanded services of anesthesiologists during the COVID-19 pandemic.

31500 – Intubation, endotracheal, emergency procedure
36620 – Arterial catheterization or cannulation for sampling, monitoring or transfusion (separate
procedure); percutaneous
36566 – Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older
92950 – Cardiopulmonary resuscitation
94002 – Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; hospital inpatient/observation, initial day
94003 – Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; hospital inpatient/observation, each subsequent day
99221 – 99233 – New or Established Patient Initial Hospital Inpatient Care Services
99231 – 99233 – Subsequent Hospital Inpatient Care Services
99291-99292 – Critical Care Services

When billing for a patient with COVID-19, the ICD-10 Coordination and Maintenance Committee has adopted the World Health Organization (WHO) diagnosis code, U07.1 (COVID-19), effective April 1. The code should be used only for confirmed cases, and providers should continue to use the previously published interim guidelines for unconfirmed cases of suspected exposure or symptoms.

According to Decision Health, U07.1 is considered a “primary code.” Physicians should also code pneumonia and all other manifestations, explained Donna Pickett, head of the diagnosis coding side of the ICD-10 Coordination and Maintenance Committee.