D9224 and D9225 are two of the more clinically specific additions in CDT 2026, and they’re already generating denials at practices that haven’t adjusted their documentation habits to match what these codes actually require. Unlike a lot of code changes that are mostly administrative, this one hinges entirely on a single clinical detail being clearly and specifically documented — and if that detail is missing, ambiguous, or inconsistent with the rest of the chart note, the claim is vulnerable.
What D9224 and D9225 are for
D9224 and D9225 are new CDT 2026 codes describing general anesthesia specifically when an advanced airway is placed and utilized throughout the procedure. D9224 covers the first 15-minute increment (or any portion of it), and D9225 covers each subsequent 15-minute increment (or any portion of it) — a time-based structure similar to the general anesthesia coding practices are already used to, but gated on the presence of advanced airway management, not just anesthesia depth.
This is a genuinely new distinction. Previously, deep sedation and general anesthesia were billed under D9222 and D9223 regardless of whether an advanced airway was placed. With the CDT 2026 update, D9222 and D9223 were revised to apply when general anesthesia or deep sedation is administered without an advanced airway, while D9224/D9225 apply specifically with one. The airway itself — not the depth of sedation, not the total time, not the setting — is what determines which code pair is correct.
Why claims are getting denied
Based on how these codes are structured, the recurring failure points are predictable:
- The chart note doesn’t specify the airway device used. CDT guidance describes qualifying advanced airways as devices like a laryngeal tube, esophageal-tracheal tube (Combitube), laryngeal mask airway (LMA), or endotracheal tube. A note that simply says “general anesthesia administered” without naming the airway device leaves a reviewer no way to confirm D9224/D9225 (versus D9222/D9223) was the correct choice.
- The airway isn’t documented as being used “throughout” the procedure. The code descriptor requires the advanced airway to be placed and utilized for the duration of the procedure, not just briefly during induction. A note describing airway placement only in an induction section, with no mention of it being maintained, invites a reviewer to question whether D9224/D9225 was appropriate.
- Anesthesia start and stop times aren’t clearly tied to the clinical definition. Anesthesia time for these codes begins when the administering doctor initiates the anesthetic agent and the required monitoring protocol and remains in continuous attendance, and ends when the patient can safely be left under the observation of trained personnel. A note with vague or missing timestamps makes it difficult to support the number of 15-minute increments billed, which is a common source of down-coding or partial denial.
- Continuous attendance isn’t documented. Because the code requires the administering doctor to remain in continuous attendance for the anesthesia time billed, any gap in the monitoring record — a chart note that jumps from induction straight to recovery without documenting ongoing attendance — creates an opening for a payer to challenge the billed time.
- The wrong code pair is billed relative to the airway used. Some practices are still defaulting to D9222/D9223 out of habit even when an advanced airway was placed and maintained throughout — which, post-CDT-2026, is now the wrong pair and can trigger a denial or a request for records once a payer’s claims-edit logic catches the mismatch.
How to fix your documentation
- Build airway device into your anesthesia note template as a required, specific field — not a checkbox for “general anesthesia,” but a named field for the actual device (endotracheal tube, LMA, laryngeal tube, or esophageal-tracheal tube) or an explicit “no advanced airway used” entry.
- Document airway maintenance explicitly, not just placement. A single line noting the airway was maintained and monitored throughout the procedure — tied to the same start/stop timeframe as the rest of the anesthesia record — closes the most common gap.
- Standardize your start/stop time documentation around the CDT definition: anesthesia begins with agent administration plus initiation of monitoring and continuous attendance, and ends when the patient can be safely left with trained personnel. Train anesthesia providers and assistants to record both timestamps consistently, not just a total elapsed time.
- Audit a sample of recent D9222–D9225 claims against the chart notes before a payer does it for you. If your documentation habits haven’t caught up to the new distinction, you’ll likely find some claims coded under the old assumption that airway status didn’t matter.
- Loop in whoever administers anesthesia, not just the front-office coder. This is a clinical documentation problem before it’s a coding problem — the coder can only bill what the chart supports, and the chart is written by the clinical team.
Practices that get this right usually make one specific change: they stop treating the anesthesia note as a narrative summary and start treating it as a structured record that mirrors the code descriptor almost line for line — airway device, continuous attendance, start time, stop time, total increments. It reads less like a story and more like a checklist, and that’s exactly what makes it defensible when a payer asks for it.
What to do if a claim has already been denied
If you’re looking at this after the fact — a D9224/D9225 claim already came back denied or downcoded — the appeal path is straightforward but only works if the underlying chart note actually supports the code. Pull the original anesthesia record and check it against the same list: named airway device, documentation that it was maintained throughout, clear start and stop times, and evidence of continuous attendance. If all of that is present but simply wasn’t summarized clearly in the claim’s supporting documentation submission, a well-organized appeal referencing the specific chart entries usually succeeds. If one of those elements is genuinely missing from the note itself, no amount of appeal language will manufacture it after the fact — which is exactly why fixing the documentation template going forward matters more than winning any single appeal.
Takeaway
D9224/D9225 denials almost always trace back to one missing detail: clear documentation that an advanced airway was placed and maintained throughout the procedure, tied to specific, consistent start and stop times. Fix the anesthesia note template first, and the coding accuracy follows.
Related specialty guides: Anesthesia Billing and Coding Guide · Dental Billing and Coding Guide