Anesthesia Coding Alert

Remember: Documentation and payer guidelines dictate coding.

Sometimes, it may seem as if there are as many ways to report labor epidurals as there are women who need them.

Why? Unlike operative anesthesia services, there is no single, widely accepted method of accounting for time for neuraxial labor analgesia,” per the American Society of Anesthesiologists (ASA) Relative Value Guide^® (RVG™). Its section on obstetric anesthesia simply states, “Professional charges and reimbursement policies should reasonably reflect the intensity and time involved in performing and monitoring any neuraxial labor analgesia.”

Sort through the maze of rules and requirements surrounding labor epidural billing with this expert insight.

Start With Correct Codes

Before you worry about how to bill the anesthesiologist’s labor epidural time, you must make sure you have identified the correct code for the epidural itself. Some payers require a surgical CPT^® code for labor epidurals, but the majority prefer the appropriate anesthesia labor analgesia code. Check the payer’s guidelines, but your most common option is:

• 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))

Depending on the situation, you might also need to report one of the two obstetrics add-on codes:

• +01968 (Anesthesia for cesarean delivery following neuraxial labor analgesia/ anesthesia …)
• +01969 (Anesthesia for cesarean hysterectomy following neuraxial labor analgesia/anesthesia …)

Tip: “If the payer requires surgical codes instead of anesthesia codes — for example, New Jersey Medicaid prefers 59409 (Vaginal delivery only (with or without episiotomy and/or forceps)) for an uncomplicated vaginal delivery and BlueCross BlueShield Kansas expects 62326 (Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus … epidural or subarachnoid, lumbar …) for lumbar epidurals in addition to 01967 and has special time reporting requirements, even though this is not one of the methods recommended by the ASA — ensure you understand payer guidelines in your state,” advises Kelly Dennis, MBA, ACS-AN, CAN-PC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Florida. “You may need to follow special payer guidelines when reporting your labor epidural claims.”

Determine Professional Charges Using These 4 Methods

Because there are no “official” rules regarding labor epidural billing, reporting these cases can be especially challenging.

“Accordingly, the RVG lists various options for capturing such time that a provider or group might adopt within their practice,” says Tony Mira, interim CEO and vice chairman, board of directors, at Coronis Health. “The ASA did not mean this list to be exhaustive but rather representative of some of the more commonly used methodologies acceptable for labor epidural billing,” he notes. They are as follows:

• Capped stick to delivery: Base units associated with the labor epidural code plus time reported in minutes (insertion through delivery), subject to a reasonable cap. Delivery may include related services such as delivery of placenta or episiotomy/laceration repair.

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 payer and verify whether it has guidelines for billing cases that go beyond labor.

• Anesthesia plus patient contact time: Base units plus one unit per hour for neuraxial anesthesia service management plus direct patient contact time (insertion, management of adverse events, delivery, removal).
• Single 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 epidural instead of billing by time units.
• Incremental time-based fees: (e.g., 0<2 hrs., 2-6 hrs., >6 hrs.)

Provide Support via Detailed Documentation

According to Mahesh Vaidyanathan, MD, MBA, in an ASA Timely Topic article: “Documentation should include all relevant clinical information. There may also be documentation requirements that are contingent upon the method used to determine fees. For example, documentation expectations for methods 1 and 3 are relatively straightforward; beyond a procedure note, documentation should include a pre-operative note, anesthesia start and stop time to capture the time-based total or incremental charge, and a post-operative note.”

Method 2 is similar to method 1 with the additional requirement to document any active interaction with the patient and management of epidural analgesia. The use of direct patient contact time does introduce some variability to the amount billed for the management of a labor epidural, however, appropriate documentation ensures and validates the additional effort required of the anesthesia professional,” Vaidyanathan adds.

Find Out if It’s All About Face Time

Note that a few payers reimburse labor epidural services based on actual face time, as opposed to the billing methodologies listed above. When submitting claims to these payers, you’ll need to know which definition of face time they use.

“Some payers may define this time as being at the patient’s bedside, while others may define it as simply being present in the labor and delivery suite. Knowing your payer rules becomes particularly important when you are managing multiple labor epidurals simultaneously within the labor and delivery suite,” Mira notes.

Tip: “Make sure you know payer guidelines for your geographical area,” Dennis adds. “You may have to report face-to-face time for Medicaid depending on your state, but you will not want to report it that way to other payers. Face-to-face time is not one of the recognized methods by the ASA, and reporting this method to all payers will cost your practice time and money,” she warns.

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, they sometimes bill for their care until that point. However, each case is different, so check the operative and anesthesia reports carefully to determine the appropriate cut-off time.

Caveat: The physician might leave the catheter in place if they plan to perform a postpartum tubal ligation the next day. In this case, the payer may only allow you to 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).

Although payer guidelines for billing labor epidurals may 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 payers 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 anesthesiologist in Albany, New York. “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.

Bottom line: Anesthesia providers must include comprehensive documentation in the patient’s record explaining their services fully to maximize coding accuracy and meet payer requirements.