Summary & Overview
CPT 4561F: Aspirin within 24 Hours Before Anesthesia for Coronary Stent Patients
CPT code 4561F identifies a perioperative quality measure indicating that a patient with a coronary stent received aspirin within the 24 hours before anesthesia started. Documenting this measure matters nationally because perioperative antiplatelet management in patients with coronary stents affects thrombotic and bleeding risks and is closely tracked by payers and quality programs. Accurate reporting supports hospital quality metrics, surgical safety reviews, and compliance with payer performance measures.
Key payers in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find context on the clinical intent of the measure, the typical service setting (hospital inpatient and outpatient surgical suites, including ambulatory surgery centers), and how this CPT Category II measure is used for perioperative quality reporting. The publication outlines benchmarks and common reporting practices, summarizes relevant policy considerations and payer expectations, and provides clinical context about perioperative aspirin use for patients with coronary stents.
This summary is written for a national audience and focuses on the code's purpose, the settings where it applies, and the stakeholder implications for hospitals, anesthesia teams, and quality officers. Data not available in the input has been omitted.
Billing Code Overview
CPT code 4561F denotes the Perioperative 2 measure: a patient with a coronary stent received aspirin within the 24 hours before anesthesia started. This measure documents perioperative antiplatelet therapy for patients with coronary stents undergoing procedures requiring anesthesia.
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Service type: Perioperative medication administration and perioperative quality measure reporting
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Typical site of service: Hospital inpatient or outpatient surgical settings where anesthesia is administered, including ambulatory surgery centers and operating rooms
Data not available in the input.
Clinical & Coding Specifications
Clinical Context
A 68-year-old male with a history of coronary artery disease and a drug-eluting coronary stent implanted 9 months prior presents for elective colon resection under general anesthesia. The perioperative team documents current pre-anesthesia medications during the preoperative assessment. The patient is taking low-dose aspirin per cardiology instructions. In the immediate preoperative period, the anesthesia record confirms that aspirin was administered or continued within the 24 hours before anesthesia start time. This documentation supports reporting 4561F to indicate the Perioperative 2 measure: a patient with a coronary stent received aspirin within 24 hours before anesthesia. Typical workflow steps include preoperative evaluation by the surgical and anesthesia teams, medication reconciliation by nursing, verification of antiplatelet therapy in the anesthesia record, and abstraction for quality/performance reporting.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
25 | Significant, separately identifiable evaluation and management service by the same physician on the day of a procedure | Use when the physician documents a distinct E/M service on the same day as the operative procedure in addition to perioperative medication documentation. |
| 57 | Decision for surgery | Use when the E/M service results in the initial decision to perform the surgery; relevant to preoperative decision-making documentation.
| 59 | Distinct procedural service | Use to indicate a distinct service or procedure separate from other procedures performed the same day when reporting unrelated services.
| 91 | Repeat clinical diagnostic laboratory test | Not typically used for 4561F but applicable when repeat lab testing is related to perioperative management.
| G0 | Emergency/Unscheduled urgent visit | Use when the procedure and perioperative documentation occur in an emergent setting requiring deviation from routine scheduling.
| G2 | Unrelated evaluation and management service by the same physician during a postoperative period | Use when an unrelated E/M is performed during the global period and must be reported separately.
| XE | Separate encounter, a different encounter (Modifier 59 subgroup) | Use to indicate services provided during a different encounter if reporting distinct services that might otherwise be bundled.
| XP | Separate practitioner (Modifier 59 subgroup) | Use when a different practitioner provides a separate service on the same day.
| XS | Separate structure (Modifier 59 subgroup) | Use when the service was performed on a separate anatomic site or organ system warranting separate reporting.
| AD | Left hand, finger, thumb (example anatomic modifier set) | Use only if reporting laterality/anatomic-specific modifiers is required by an associated procedure; not typically applicable to 4561F itself.
| Taxonomy Code | Specialty | Notes |
|---|---|---|
207R00000X | Anesthesiology | Anesthesiologists document pre-anesthesia medication reconciliation and start time of anesthesia. |
| 207L00000X | Surgery | Surgeons coordinate perioperative management and decision-making for continuation of antiplatelet therapy.
| 363A00000X | Cardiology | Cardiologists provide guidance on timing and necessity of aspirin for patients with coronary stents.
| 390200000X | Nursing | Preoperative and PACU nurses perform medication reconciliation and document administration.
Related Diagnoses
| ICD-10 Code | Description | Clinical Relevance |
|---|---|---|
I25.10 | Atherosclerotic heart disease of native coronary artery without angina pectoris | Chronic coronary artery disease with prior stenting; relevant to perioperative antiplatelet management and 4561F reporting. |
| I25.110 | Atherosclerotic heart disease of native coronary artery with unstable angina | Indicates coronary disease that may influence perioperative aspirin decisions and documentation.
| I21.3 | ST elevation (STEMI) myocardial infarction of unspecified site | Acute coronary syndrome history pertinent to antiplatelet therapy and perioperative planning.
| Z95.5 | Presence of coronary angioplasty implant and graft | Explicitly documents presence of a coronary stent or angioplasty implant, directly tying the patient to the population for whom 4561F applies.
| I20.9 | Angina pectoris, unspecified | Symptomatic coronary ischemia history that may affect perioperative antiplatelet management and documentation.
Related CPT Codes
| CPT Code | Description | Relationship to This Procedure |
|---|---|---|
00100 | Anesthesia for procedures on salivary glands, including biopsy; general anesthesia not otherwise specified | Example anesthesia code category; anesthesia start time documentation is required to determine the 24-hour window for 4561F reporting when general anesthesia is provided for surgery. |
| 99221 | Initial hospital care, per day, for the evaluation and management of a patient | Preoperative E/M codes commonly appear in the same clinical workflow; documentation of medication reconciliation and perioperative assessment supports 4561F abstraction.
| 36591 | Insertion of tunneled centrally inserted central venous catheter, without subcutaneous port or pump | Represents other perioperative services that may occur in the same episode of care; included as commonly occurring concurrent procedures in surgical patients.
| 93000 | Electrocardiogram, routine EKG with at least 12 leads; with interpretation and report | Preoperative ECGs are commonly performed in patients with coronary stents as part of perioperative cardiac risk assessment; occurs before anesthesia start.
| 99100 | Anesthesia for patient of extreme age, under 1 year or over 70 years, requiring certain monitoring | Anesthesia-related modifiers/circumstances commonly documented in older surgical patients; relevant to the perioperative environment where 4561F is captured.