Anesthesia Coding Alert

Accurate documentation can carry the claim.

An anesthesia claim is based on a combination of factors: time spent, service rendered, provider, and more. Reporting all the correct variables can be confusing, especially with services such as labor epidurals that can quickly become complicated.

Your key to success lies in having clear documentation of every detail. Train your anesthesia providers to focus on these four areas when they administer labor epidurals, and your coding won’t be nearly so painful.

Focus 1: Select the Best Service Code

Reporting a labor epidural begins with the correct anesthesia CPT^® code. Your choices are:

• 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))
• +01968 (Anesthesia for cesarean delivery following neuraxial labor analgesia/ anesthesia (List separately in addition to code for primary procedure performed))
• +01969 (Anesthesia for cesarean hysterectomy following neuraxial labor analgesia/ anesthesia (List separately in addition to code for primary procedure performed)).

However: Payers expect more than the appropriate code on the claim. Your anesthesia providers should include other notes on the patient’s record to explain the service more fully so your coding can be more accurate and meet payer requirements.

For example, a patient experiencing labor comes to the hospital at 37 6/7 weeks’ gestation. If the anesthesiologist notes that the case becomes a cesarean delivery but doesn’t explain why, you don’t have much documentation to support your claim for 01967 and +01968. Better documentation would include a note such as, “Failure to progress resulted in emergency c-section.”

Remember: The diagnosis code (reason) for the placement of the epidural will be different that the diagnosis code (reason) for the c-section.

Having more detailed notes from your providers means you’ll report an associated diagnosis such as O66.40 (Failed trial of labor, unspecified) instead of resorting to a general diagnosis such as O82 (Encounter for cesarean delivery without indication).

Be sure to watch for coding guidelines such as the one with O82 directing you to submit an additional code from Z37 (Outcome of delivery) indicating the outcome of delivery (single or multiple birth, live birth or stillborn, etc.).

“Although not all insurance companies look for these additional codes, some may,” says Kelly D. Dennis, MBA, ACS-AN, CAN-PC, CHCA, CPMA, CPC, CPC-I, owner of the consulting firm Perfect Office Solutions in Leesburg, Florida. “If you are not reporting, watch out for denials.”

Focus 2: Document the Anesthesia Provider

Multiple members of the anesthesia team sometimes become involved with labor patients, especially when cases cross work shifts. The anesthesia record should clearly document:

• Who performed the preoperative exam
• Who inserted the epidural catheter
• Who monitored the patient during labor
• Who removed the catheter following delivery.

The easiest way to document these details is to use a template or have check boxes for the providers to mark — but that doesn’t mean it’s the best way to meet documentation guidelines.

“Anyone can check a box,” Dennis points out. “Having the providers’ initials or signatures are more clear indications of who was actually involved in the case.”

If different physicians are involved in parts of the case (i.e., pre-op, placement, and removal), then documentation should show each name/signature and the time he or she spent with the patient.

Tip: Some anesthesia groups use special labor or epidural forms to document these cases. Other groups use a standard anesthesia record to track and monitor patient care and indicate provider involvement. The most important thing is for your practice to consistently use a form that the providers understand and complete accurately.

Focus 3: Check When Monitoring Occurred

Labor can last for hours, which means an anesthesia team member won’t just insert the epidural and hover by the patient’s bedside until everything is over. Instead, different members of the anesthesia team will be in and out to monitor the patient’s progress and the epidural’s effectiveness throughout labor and delivery.

Keep these pointers in mind when you’re educating anesthesia providers about thoroughly documenting labor epidurals:

• How often did someone monitor the patient? Most payers don’t have specific guidelines for an acceptable timeline for labor epidurals, so your group might not need them either. “I’m not sure I would set time limits for this,” Dennis says. “It should depend on the patient’s needs.” For example, a severely pre-eclamptic patient (O14.1-, Severe pre-eclampsia) carrying twins needs more monitoring than a healthy patient with an uncomplicated labor (O80, Encounter for full-term uncomplicated delivery). Patient preference also can dictate monitoring because some patients are needy while others prefer minimal interruptions.
• How much time did the anesthesiologist spend monitoring the patient? “This is a good way to show whether the anesthesiologist spent an extensive amount of time with the patient,” Dennis explains.
• What happened when the anesthesiologist monitored her? Some insurers expect to find a recorded blood pressure measurement for every five minutes of face time with the patient. Other interventions could include topping off the epidural, decreasing the epidural level, or changing drugs.

Why it’s important: Documenting these factors helps you assign the correct time units when you’re coding each anesthesia provider’s involvement in the case and when you’re tracking concurrencies for a medically directing anesthesiologist.

“This documentation is also necessary for payers requiring “time in attendance” is reported on the claim,” Dennis says.

Focus 4: Verify Whether Modifiers Apply

If the case you’re coding involves a Medicare patient, complete your claim by including performance modifiers with the delivery code as appropriate:

• AA (Anesthesia services performed personally by anesthesiologist)
• QZ (CRNA service: without medical direction by a physician)
• QX (CRNA service: with medical direction by a physician)
• QY (Medical direction of one certified registered nurse anesthetist [CRNA] by an anesthesiologist)
• QK (Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals)
• AD (Medical supervision by a physician: more than four concurrent anesthesia procedures)

Remember: Many commercial payers (such as Blue Cross and Blue Shield in California) do not accept medical direction modifiers, and some payers or states do not recognize CRNAs as providers unless they are medically directed. Verify the carrier’s guidelines before submitting any of the performance modifiers.