# Spinal/Epidural Combinations



## amieelyn2001 (Nov 21, 2011)

My two doctors are doing spinal/epidural combinations for their total hip patients. They are doing the procedures at the same time, but for different purposes. The spinal is the method of anesthesia and the epidural is used after the procedure for post-op pain. 

Can both still be billed since they are inserting the epidural catheter at the same time as doing the spinal block?

Thanks!!!


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## dwaldman (Nov 22, 2011)

http://www.cms.gov/nationalcorrectcodinited/

Chapter II
Anesthesia Services
CPT Codes 00000 – 09999
FOR 
NATIONAL CORRECT CODING INITIATIVE POLICY MANUAL 
FOR MEDICARE SERVICES

CPT codes 62310-62311 and 62318-62319 (Epidural or subarachnoid injections of diagnostic or therapeutic substance) may be reported on the date of surgery if performed for postoperative pain management rather than as the means for providing the regional block for the surgical procedure. If a narcotic or other analgesic is injected through the same catheter as the anesthetic agent, CPT codes 62310-62319 should not be reported. Modifier 59 may be reported to indicate that the injection was performed for postoperative pain management, and a procedure note should be included in the medical record.

 Pain management performed by an anesthesia practitioner after the postoperative anesthesia care period terminates may be separately reportable. However, postoperative pain management by the physician performing a surgical procedure is not separately reportable by that physician. Postoperative pain management is included in the global surgical package.

Example: A patient has an epidural block with sedation and monitoring for arthroscopic knee surgery. The anesthesia practitioner reports CPT code 01382 (Anesthesia for diagnostic arthroscopic procedures of knee joint). The epidural catheter is left in place for postoperative pain management. The anesthesia practitioner should not also report CPT codes 62311 or 62319 (epidural/subarachnoid injection of diagnostic or therapeutic substance), or 01996 (daily management of epidural) on the date of surgery. CPT code 01996 may be reported with one unit of service per day on subsequent days until the catheter is removed. On the other hand, if the anesthesia practitioner performed general anesthesia reported as CPT code 01382 and at the request of the operating physician inserted an epidural catheter for treatment of anticipated postoperative pain, the anesthesia practitioner may report CPT code 62319-59 indicating that this is a separate service from the anesthesia service. In this instance, the service is separately reportable whether the catheter is placed before, during, or after the surgery. Since treatment of postoperative pain is included in the global surgical package, the operating physician may request the assistance of the anesthesia practitioner if the degree of postoperative pain is expected to exceed the skills and experience of the operating physician to manage it. If the epidural catheter was placed on a different date than the surgery, modifier 59 would not be necessary. Effective January 1, 2004, daily hospital management of continuous epidural or subarachnoid drug administration performed on the day(s) subsequent to the placement of an epidural or subarachnoid catheter (CPT codes 62318-62319) may be reported as CPT code 01996.


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## dwaldman (Nov 22, 2011)

Below is from 2001 Oct CPT Assistant

The following article builds on information originally presented in the February 1997 CPT Assistant article, "Anesthesia: Coding for Procedural Services."

Codes for procedures commonly used in the management of postoperative pain include 62318 and 62319 (both introduced in CPT 2000) for continuous epidural analgesia and the series of codes for somatic nerve blocks (64400-64450).

It is appropriate to report pain management procedures, including the insertion of an epidural catheter or the performance of a nerve block, for postoperative analgesia separately from the administration of a general anesthetic.

When general anesthesia is administered and these injections are performed to provide postoperative analgesia, they are separate and distinct services and are reported in addition to the anesthesia code. Whether the block procedure (insertion of catheter; injection of narcotic or local anesthetic agent) occurs preoperatively, postoperatively, or during the procedure is immaterial.

If, on the other hand, the block procedure is used primarily for the anesthesia itself, the service should be reported using the anesthesia code alone. In a combined epidural/general anesthetic, the block cannot be reported separately.

Examples

• A patient having total knee replacement surgery may receive a regional anesthetic and a postoperative pain management agent through the same epidural catheter, in which case the only code reported would be 01402.


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## coffee2day (Feb 23, 2016)

Just wanted to reply to this old thread regarding the same question.

A provider is billing general, spinal and femoral block for  a knee procedure. The spinal and general are a combined form of anesthesia and the spinal should not be separately billable per the CPT assistant from 2001 guidance. 

The provider is arguing that the spinal should qualify as a separate charge for this specific patient example - the patient requested a general anesthetic, the surgeon and I both agree that the spinal is still warranted for the benefits that it provides us validating its use. For many patients, the usual routine is that the spinal is enough to allow them to get through the procedure with just sedation, but this specific patient would not be happy with this and wanted general. 

I still feel the requested 'general' along with the routine spinal is a combined form and the spinal block cannot be separately billable, any advice on this or other resources to post regarding this issue? Any info would be greatly appreciated.


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## dwaldman (Feb 24, 2016)

Below is another reference from the NCCI policy manual regarding, reporting a epidural code if for postop pain management.

https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html

CHAPTER II ANESTHESIA SERVICES CPT CODES 00000-09999  FOR NATIONAL CORRECT CODING INITIATIVE POLICY MANUAL FOR MEDICARE SERVICES 

  4.  Under certain circumstances an anesthesia practitioner may separately report an epidural or peripheral nerve block injection (bolus, intermittent bolus, or continuous infusion) for postoperative pain management when the surgeon requests assistance with postoperative pain management.  An epidural injection (CPT code 623XX) for postoperative pain management may be reported separately with an anesthesia 0XXXX code only if the mode of intraoperative anesthesia is general anesthesia and the adequacy of the intraoperative anesthesia is not dependent on the epidural injection.  A peripheral nerve block injection (CPT codes 64XXX)for postoperative pain management may be reported separately with an anesthesia 0XXXX code only if the mode of intraoperative anesthesia is general anesthesia, subarachnoid injection, or epidural injection, and the adequacy of the intraoperative anesthesia is not dependent on the peripheral nerve block injection.  An epidural or peripheral nerve block injection (code numbers as identified above) administered preoperatively or intraoperatively is not separately reportable for postoperative pain management if the mode of anesthesia for the procedure is monitored anesthesia care (MAC), moderate conscious sedation, regional anesthesia by peripheral nerve block, or other type of anesthesia not identified above.  If an epidural or peripheral nerve block injection (code numbers as identified above) for postoperative pain management is reported separately on the same date of service as an anesthesia 0XXXX code, modifier 59 may be appended to the epidural or peripheral nerve block injection code (code numbers as identified above) to indicate that it was administered for postoperative pain management.  An epidural or peripheral nerve block injection (code numbers as identified above) for postoperative pain management in patients receiving general anesthesia, spinal (subarachnoid injection) anesthesia, or regional anesthesia by epidural injection as described above may be administered preoperatively, intraoperatively, or postoperatively.


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## coffee2day (Feb 25, 2016)

Thank you.


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