Anesthesia Coding Alert

If the carrier requires surgical codes instead of anesthesia codes, Sharon Merrick, CCS-P, coding and reimbursement analyst for the American Society of Anesthesiologists, recommends 59409 (Vaginal delivery only [with or without episiotomy and/or forceps]) for an uncomplicated vaginal delivery.

Double-Check How to Report the Time

Next, check your physician group's policy for reporting the anesthesia provider's time during labor cases. Billing for the amount of time involved with each procedure (along with the appropriate anesthesia code) is unique to anesthesia billing. No "official" rules regarding labor epidural billing exist, which makes these cases especially tricky.

Start with a good understanding of what "time" really is. The American Society of Anesthesiologists (ASA) defines anesthesia time as follows: "Anesthesia time begins when the anesthesiologist begins to prepare the patient for anesthesia care in the operating room or in an equivalent area, and ends when the anesthesiologist is no longer in personal attendance, that is, when the patient may be safely placed under postanesthesia supervision."

According to this definition, the physician in this case must be in personal attendance (known as "face-to-face" time) for the 15 minutes after the labor ended before you can bill for it. But don't dismiss these three other common alternative billing methods that carriers might allow:

Billing a flat fee for all labor epidurals - You still report the total time for the physician's involvement, but bill the same dollar amount for each labor case instead of billing by time units.

Billing the anesthesiologist's time from catheter insertion to removal (that is, the time the catheter is used) - This method of reporting time is easy to bill (assuming the physician adequately documents the case) but still includes some caveats you should check. First, check whether the carrier caps the amount of time you can bill for a labor case; Florida Medicaid, for example, has a six-hour cap on the billable amount of time in these cases. Second, verify whether the carrier has guidelines for billing cases that go beyond labor.

Example: The physician might leave the catheter in place if he plans to perform a postpartum tubal ligation the next day. In this case, the carrier probably allows you to only bill for the labor epidural through the actual delivery time. The anesthesiologist uses the same catheter the next day to administer anesthesia during the tubal ligation (00851, Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; tubal ligation/transection).

Billing the anesthesiologist's time with an upper-limit cap - This popular billing method is easy to calculate and helps claims get processed easily. The drawback is that it can be difficult to justify from a compliance standpoint because it doesn't document face-to-face time with the patient. You also need to negotiate a reasonable cap with the carrier.

Know When to End It

Many anesthesiologists feel responsible for the epidural (and, therefore, the patient) until someone pulls the catheter. If the anesthesiologist removes the catheter instead of having a nurse do it, he sometimes bills for his care until that point.

"It's probably appropriate to bill for 15-30 minutes of care after the delivery time," says Tonia Raley, CPC, claims manager with Medical Information Management Solutions in Phoenix. "Using this as your end time makes sense because there still is a residual anesthetic effect." But each case is different, so check the operative and anesthesia reports carefully to determine the appropriate cut-off time.

Although carrier guidelines for billing labor epidurals might vary, one thing should be consistent - they should not include written rules that specify a certain time frame for the amount of time allowed. The actual amount of time the physician must remain with the patient will depend on the individual case, so carriers should not cut this time at a certain point.

"Labor - and the anesthesiologist's involvement in the case - does not end with the baby's birth," says Scott Groudine, MD, an Albany, N.Y., anesthesiologist. "The physician often delivers the placenta 5-15 minutes after the birth, which means the anesthesiologist is still present. Patients also often need anesthesia during an episiotomy or if the physician repairs vaginal lacerations. A third- or fourth-degree episiotomy repair could take up to an hour to fully repair.

"If the anesthesiologist is present and provides service, then billing for the time involved is appropriate."