Anesthesia Coding Alert

Know when – and if -- +01968 comes into play.

Coding for obstetrical cases always has the potential to get tricky, thanks to all the variations you can encounter in a case. That can especially be true with code 01967 (Neuraxial labor analgesia/anesthesia for planned vaginal delivery (this includes any repeat subarachnoid needle placement and drug injection and/or any necessary replacement of an epidural catheter during labor)), so read on for some real-world Q&A that will help you decipher when – and when not – to report it.

Choosing Whether 01967 or +01968 Is Better

Question 1: Medicaid in our state has a guideline stating that “when a vaginal delivery becomes a C-section and the catheter remains in place for the C-section, you may bill for the vaginal delivery 01967 or the C-section +01968 (Anesthesia for cesarean delivery following neuraxial labor analgesia/anesthesia [list separately in addition to code for primary procedure performed]), whichever is the most appropriate. A provider may not bill for both.” Reimbursement for both codes is the same. How should I determine which is “most appropriate”?

Answer 1:  Anytime a planned vaginal delivery turns into a C-section, report a C-section code for the procedure. Some insurers have specific guidelines for these cases, so it’s important to understand the parameters for the payer in question. For example, some payer rules state that if the physician places an epidural for a planned vaginal delivery and the patient delivers by c-section instead, the “most appropriate” code to use is +01968. In that situation you would report the total amount of face-to-face time with +01968 because the payer allows you to bill +01968 as a primary code instead of only as an add-on.

If your state’s guidelines say that either 01967 or +01968 is acceptable, check with your payer representative to confirm when they expect you to use each code.

Remember that 01967 Can Trump 62326

Question 2: An expectant mom came to the hospital at the 37-week mark and was given an epidural. It was then removed with a time of 2036-0840 without her delivering. Should this be coded as 62326 or 01967?

Answer 2: Coding for labor and delivery cases can get tricky, especially since the anesthesia service can change from what is originally expected, says Kelly Dennis, MBA, ACS-AN, CAN-PC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Fl.

When no delivery occurs and the patient is sent home, many practices report 01967 with modifier 53 (Discontinued procedure).

Explanation: It’s better to report 01967 in this situation than 62326 (Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance). Why? Years ago, coders reported 62319 for labor epidurals, but that code was replaced by 62326 when many epidural codes were revamped effective January 1, 2017. In today’s coding world, 62326 is set as a flat-fee procedure code and isn’t intended for labor epidurals anymore. Code 01967 is anesthesia specific and includes time, so is a better choice.

Verify Anesthesia Type to Separate 01967 from 01960

Question 3: Most of our physicians report 01967 for vaginal deliveries. What is the difference between 01967 and 01960, and when should I use each code?

Answer 3: Both 01960 (Anesthesia for vaginal delivery only) and 01967 can be reported for vaginal deliveries. The dividing line lies with the type of anesthesia administered.

Code 01967 is specific to neuraxial analgesia. Report this when your anesthesia provider places an epidural or administers spinal mediations during the course of the patient’s labor. The service does not require a catheter. Report 01960 in other situations when the provider does not provide labor analgesia.

Example: The anesthesiologist might be called in for the delivery because the patient is in too much pain or the obstetrician is having problems. Instead of using an epidural, the provider might administer a spinal block or an injection to ease the patient’s pain. That situation would point you to01960.

Another tip: Per Relative Value Guide (RVG^®) comments, report 01960 when the anesthesiologist is only involved during a vaginal delivery, without providing any labor analgesia/anesthesia care. Report 01967 when the anesthesia provider places a catheter and is involved with the patient’s labor and delivery.

Monitoring Can Still Count as 01967

Question 4: Our anesthesiologist began an epidural for a labor patient and periodically monitored her for several hours. He removed the epidural and she was transported to another hospital, where she eventually delivered (31 weeks gestation). How should I code our anesthesiologist’s work?

Answer 4: Begin with 01967, which is 5 base units. Append modifier 53 (Discontinued procedure) to indicate that the physician discontinued use of the epidural and include supporting documentation to explain the case.

Also submit diagnosis O60.02 (Preterm labor without delivery, second trimester) or O60.03 (Preterm labor without delivery, third trimester), based on the trimester.

Count time carefully: Providers have several options for reporting anesthesia time for laboring epidural patients, so it’s important to know the carrier’s policy beforehand. For example, some carriers require that you only report the actual face-to-face time the anesthesia provider spent with the patient; other carriers may have policies directing you to report the physician’s time as 1 unit for each hour the epidural is in place.

Consider Physical Status, But Don’t Change Main Code

Question 5: If an obstetrics patient is classified as P3 when she comes to the hospital for delivery, should I report on both 01967 and +01968?

Answer 5: Physical status can help justify anesthesia in some situations and help document the level of risk involved in caring for the patient, although some carriers don’t pay additional units for higher physical status modifiers (such as P3, A patient with severe systemic disease; and P4, A patient with severe systemic disease that is a constant threat to life). Adding these physical status modifiers to 01967 is no different than using them with any other case that warrants them.

Also remember that there might be times when the patient’s physical status changes between the time when she presents for delivery (as a P2, for example) and then experiences a problem that requires a C-section (which could shift her status to P3).

Final tip: If you are not sure whether or not the insurance accepts the modifier, Dennis advises that you include the modifier on the claim. “No insurance will cover unreported services,” she says. If the modifier is not needed, the insurer will ignore it.