Anesthesia Coding Alert

Let these three scenarios guide you through the dos and don’ts of reporting 01996.

In some cases, anesthesia coding may be a simple task, particularly when it’s a straightforward service that is clearly documented in the medical record. But when the anesthesiologist is asked to also provide postoperative management of continuous drug administration via epidural or subarachnoid catheter, questions can arise regarding when you can — or should — report 01996 (Daily hospital management of epidural or subarachnoid continuous drug administration).

To help you gauge your level of expertise in coding these more complex cases involving post-op neuraxial pain management services, we’ve put together a quick quiz. So put on your thinking cap and try answering the following case scenarios.

Question 1: An anesthesiologist inserts a lumbar epidural catheter without imaging to manage post-op pain following major abdominal surgery. After anesthesia time ended, a different anesthesiologist was called back to place a lumbar catheter in the post-anesthesia care unit (PACU) to administer epidural analgesics as a continuous infusion based on the surgeon’s written orders. Can you bill the catheter separately, and if so, how? Also, how do you handle coding when the anesthesiologist visits the patient the next day to see how the continuous epidural is working?

Question 2: The anesthesiologist performs an epidural on an obstetrics patient prior to her cesarean section and administers a specific brand-name preservative-free morphine. Should you submit 01996 for using the drug during the procedure?

Question 3: You’re faced with coding the last day of post-op pain management and catheter removal. No bolus was administered, and the anesthesiologist’s documentation doesn’t meet standard evaluation and management (E/M) requirements.

Think you can solve these continuous drug administration management coding conundrums? Click here to review the answers.