Anesthesia Coding Alert

Grab your answers and see if you really are an anesthesiology coding expert.

Once you’ve answered the questions on pages 3 and 4, compare your responses with the ones provided below.

Submit 01996 for Additional Days Following Epidural Block

Answer 1: Since the anesthesiologist did not employ the epidural catheter as a means of anesthesia for the surgery, then you can use 62326 (Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) … interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance) to report the lumbar epidural catheter placement.

Because a different physician administered the block on the same day as surgery, make sure to submit 62326 with the appropriate modifier appended, such as -XP (Separate practitioner …) or -59 (Distinct procedural service). This communicates to the payer that a different provider inserted the epidural catheter for postoperative pain management only and not as a means of anesthesia for the abdominal surgery.

Same-day visits by your anesthesiologist after postoperative epidural catheter placement are not separately billable. However, if your provider needs to see the patient on subsequent days to manage the continuous pain medication infusion, then as directed by the CPT® parenthetical note, “Report 01996 [Daily hospital management of epidural or subarachnoid continuous drug administration] for daily hospital management of continuous epidural or subarachnoid drug administration performed after insertion of an epidural or subarachnoid catheter.”

Tips: Submit 01996 once per day, as it includes all evaluation and management (E/M) services associated with continuous drug infusion management regardless of how many times the doctor saw the patient. Make sure to double-check the documentation to ensure it supports the visit and any medical decisions made.

Don’t Bill 01996 After Single-Shot Morphine Administration

Answer 2: Preservative-free morphine, such as Duramorph or Astramorph, is administered via a single epidural or intrathecal application. This means that even if the anesthesiologist administers the drug through a catheter, it is a single-shot injection rather than continual administration. Since 01996 represents continuous infusion, you cannot report 01996 in this situation.

Remember: When you code this type of case, the original anesthetic includes the patient’s first day of post-op pain management — that is, the code you reported for the labor and delivery, such as 01967 (Neuraxial labor analgesia/anesthesia for planned vaginal delivery …) and +01968 (Anesthesia for cesarean delivery following neuraxial labor analgesia/anesthesia …). “Any use of 01996 would begin the following day and would only apply if the catheter was left in place, which is not typically the case,” says Kelly D. Dennis, MBA, ACS-AN, CAN-PC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Florida.

Don’t miss: The anesthesiologist should monitor the patient’s vitals after morphine administration due to the risk of respiratory distress. Depending on payer policy, you may be allowed to separately report a code, such as 99231 (Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient ...), for this service. If your physician gave preservative-free morphine and subsequently managed and documented the patient’s post-op pain, you may be able to bill 99231 the following day, providing the documentation supports the level of service for an E/M.

“If the patient has an issue that needs to be addressed, it is possible to meet the level of an E/M code for this service,” Dennis notes. Keep in mind, “routine follow-up may fall under the global for anesthesia services,” she adds.

Let Documentation Guide 01996 Usage on Last Management Day

Answer 3: Billing 01996 on the day of catheter removal depends on whether the physician provides any other services (i.e., management of catheter site redness, itching, and irritation) for the patient that day. If the physician removes the catheter and doesn’t provide any other services, do not report an additional charge — catheter removal is an expected service. However, if your physician provides other services and makes the decision to remove the catheter the following day, you can report 01996 for the day of services “but not on the day of removal — unless another medical decision was made over and above removing the catheter and is supported by the documentation,” explains Dennis.

Add More Advice to Your Coding Arsenal

“I’m sometimes asked if 01996 needs a performance modifier such as AA,” says Catherine Brink, BS, CPC, CMM, president of Healthcare Resource Management in Spring Lake, New Jersey. “It does not need one of these modifiers, so don’t append one.”

Also important: When coding for post-op pain management, be sure to count the days correctly. The original anesthetic includes the patient’s first day of postoperative pain management – the code you reported for the original procedure such as 62326 (Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) … interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance). Any use of 01996 would begin the following day.

Often the payer’s policy will define how many days are allowed for 01996, Dennis notes. If it is medically necessary to exceed the number of days outlined in the policy, your provider must document the reason post-op pain management is still needed.

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