Anesthesia Coding Alert

Remember: Anesthesiologists cannot bill for the provision of PCA.

In some cases, coding for anesthesia during a cesarean delivery (cesarean section, c-section) may be a simple task, particularly when it’s a straightforward procedure that the physician clearly documents in the medical record. But c-section coding can get complicated, even for experienced coders.

Avert billing blunders by refreshing your knowledge of how to handle these four common c-section anesthesia scenarios.

Do This When Vaginal Delivery Changes to C-Section

Anytime a planned vaginal delivery turns into a cesarean section, report a c-section code for the anesthesia services provided during cesarean delivery.

Example: A patient had an epidural for labor from 17:16 to 22:12, and then a c-section and ovarian cystectomy (compound presentation and adnexal complex mass) from 22:12 to 23:10. How do you code this delivery and surgery?

“You should choose to report the highest base procedure(s), which in this case is epidural to c-section,” explains Kelly D. Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Florida.

“Planned vaginal deliveries often turn to c-sections,” Dennis adds. When they do, you’ll use codes:

• 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)) and
• +01968 (Anesthesia for cesarean delivery following neuraxial labor analgesia/ anesthesia (List separately in addition to code for primary procedure performed)).

Code 01967 carries a base unit value of 5; code +01968 has a value of either 2 or 3 units, depending on the insurer.

Important: Some payers have specific guidelines for these cases. For example, Texas Medicaid rules state “for a Cesarean delivery following a planned vaginal delivery, the anesthesia administered during labor must be billed with procedure code 01967 and must indicate the time in minutes that represents the time between the start and stop times for the procedure. The additional anesthesia services administered during the operative session for a Cesarean delivery must be submitted using procedure code +01968 or +01969 and must indicate the time spent administering the epidural and the actual face-to-face time spent with the client.” (www.tmhp.com/sites/default/files/ file-library/resources/provider-manuals/tmppm/pdf-chapters/2023/2023-01-january/2_ Med_Specs_and_Phys_Srvs.pdf)

Match the Anesthesiologist and CRNA Codes

When an anesthesiologist provides the epidural for the labor portion of a delivery and then directs a CRNA during the c-section portion of the encounter, the anesthesiologist and the CRNA should bill with the same ASA codes.

In this instance, the anesthesiologist would bill 01967 with modifier AA (Anesthesia services performed personally by anesthesiologist) appended and +01968 with either QK (Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals) or QY (Medical direction of one certified registered nurse anesthetist (crna) by an anesthesiologist). You should not veer from those codes when billing for the CRNA. So, for the CRNA, report +01968 with modifier QX (CRNA service: with medical direction by a physician).

Don’t get tripped up: While you might be tempted to use code 01961 (Anesthesia for cesarean delivery only) for the CRNA’s services, that would not be correct because this code indicates that only a c-section was performed and that the patient did not receive any labor analgesia/anesthesia, which is not the situation in this case.

In addition, Relative Value Guide^® (RVG™) guidelines state that you should not report code 01961 in conjunction with 01967. This patient had a trial of labor. Therefore, it would be inappropriate to bill 01961.

Tip: Be sure to separate the anesthesia time for the labor epidural from the time for the c-section. Note that depending on your software system, you may need to use the same minute for the start of the c-section (22:12) as the epidural end time, or the next minute (22:13).

Before submitting the claim, check the payer’s guidelines, as some may require the diagnoses and ICD-10-CM codes for the labor epidural and the c-section to be different.

Handle Anesthesia Gap Between Labor and C/S Like This

Another tricky scenario is when two types of anesthesia are provided, and they are given non-consecutively. Bottom line, insurance companies do not typically pay by the “type” of anesthesia, so you should report both services and specify the times for each.

Example: A patient in labor was started with lumbar epidural anesthesia (LEA). The LEA became insufficient, and the patient had no monitoring or medications for about an hour. The patient was taken to the operating room (OR) for a cesarean section, where the anesthesiologist used a subarachnoid (spinal) block (SAB) for the procedure. The LEA line was removed in the OR. Since the anesthesia was not continuous from the time of labor through the c-section, what is the best way to code the case?

The clearest way to explain this scenario is to report 01967 with the associated documented time and diagnosis for the initial labor epidural. Also, include add-on code +01968 with the associated documented time and diagnosis for the c-section. “Make sure to check for any local policies that cap time or have specific time requirements,” Dennis advises. “Although the American Society of Anesthesiologists (ASA) does not recognize ‘face’ time as one of the methods for reporting labor epidural time, some state Medicaid plans require documentation of each patient contact during the epidural,” she notes.

Do This When PCA Shifts to C/S Anesthesia

While not common, there are times when a patient is receiving labor pain control via patient-controlled analgesia (PCA) and ends up needing a c-section. The key thing to remember in this situation is that the PCA isn’t a separate service the physician can bill.

Example: A patient who was not a candidate for a labor epidural was placed on a remifentanil PCA and subsequently needed a cesarean section. Because of the circumstances, the anesthesiologist was present and provided anesthesia for the entire case.

In this scenario, you can report 01961 with the documented anesthesia time for the c-section. But you should not report the PCA as a separate anesthesia service.

Explanation: When a doctor orders intravenous (IV) medication, there is nothing billable to the physician. Ordering treatment is part of a physician’s job and is included in the care they provide to the patient. In addition, PCA is patient-controlled analgesia through an IV. The medication is brought to the patient care area in a cartridge that a nurse inserts into the IV pump and programs. The process does not require a doctor to be physically involved at the patient’s bedside, so if no anesthesia service was actually provided, no anesthesia billing would apply.