Anesthesia Coding Alert

Once again, documentation will make or break your claim.

You can report postoperative services administered by your anesthesiologist, provided you have clear documentation of certain factors. The next time you’re looking at a claim for post-op care such as an injection or catheter insertion, check out this expert guidance to help determine if you’re in the clear to submit 01996 (Daily hospital management of epidural or subarachnoid continuous drug administration).

Code 01996 Might Be Allowed for Days Following Epidural Block

Scenario 1: The anesthesiologist inserts a lumbar epidural catheter to manage post-op pain following a patient’s total knee replacement surgery. While in the post-anesthesia care unit (PACU), he connects the catheter to medication as a continuous infusion. She visits the patient the next day to check how the continuous epidural is working.

Answer 1: If the anesthesiologist did not use the epidural catheter as a means of anesthesia for the surgery, then you can use 62326 (Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance), to report the epidural catheter placement. Because the anesthesiologist administered the block on the same day as surgery, append modifier 59 (Distinct procedural service) to 62326. This lets the payer know that your provider performed the epidural procedure for post-operative pain management only and not as a means of anesthesia during the surgery.

Same-day visits by your anesthesiologist after post-operative placement of the epidural catheter are not separately billable. However, if your provider needs to see the patient on subsequent days to manage the continuous pain management infusion, follow this guidance according to CPT^® coding notes: “Report 01996 for daily hospital management of continuous epidural or subarachnoid drug administration performed after insertion of an epidural or subarachnoid catheter.”

Translation: Submit 01996 once per day as it includes all E/M services associated with the continuous infusion management regardless of how many times the doctor saw the patient.

Steer Clear of 01996 After Single-shot Morphine Administration

Scenario 2: The anesthesiologist provides an epidural (brand-name preservative-free morphine) to an OB patient prior to her cesarean section. He uses a specific brand-name preservative-free morphine.

Answer 2:  Preservative-free morphines (such as Duramorph or Astramorph) are administered with a single application. This means that even if the anesthesiologist administers the drug through the catheter, it is a single-shot infusion rather than continual. Code 01996 represents continuous infusion, so you cannot report 01996 in this situation.

The anesthesiologist should monitor the patient’s respiration after morphine administration due to the risk of respiratory distress. Depending on insurer policy, you may be allowed to separately report 99231 (Subsequent hospital care, per day, for the evaluation and management of a patient ...) for this service. If your physician gave preservative-free morphine and subsequently managed and documented the patient’s post-op pain, you may be able to bill 99231 on the first day of post-op care, providing the documentation supports the level of service for an evaluation and management.

“If the patient has an issue that needs to be addressed, it is possible to meet the level of an E/M code for this service,” says Kelly Dennis, MBA, ACS-AN, CAN-PC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Fl. “Routine follow-up would fall under the global for anesthesia services.”

Check Whether 01996 Is Appropriate on Last Management Day

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

Answer 3: Billing 01996 on the day of catheter removal depends on whether the physician provides any other services for the patient that day. If the physician removes the catheter and doesn’t provide any other services, do not report an additional charge (catheter removal is an expected service). If your physician provides other services and makes the decision to remove the catheter the following day, you can report01996 for the day of services but on not the day of removal.

Add More Advice to Your Coding Arsenal

“I’m sometimes asked if 01996 needs a performance modifier such as AA,” says Catherine Brink, BS, CPC, CMM, president of Healthcare Resource Management in Spring Lake, NJ. “It does not need one of these modifiers, so don’t append one.”

Also important: When coding for post-op pain management, be sure to count the days correctly. The original anesthetic includes the patient’s first day of postoperative pain management – the code you reported for the original procedure such as 62326 (Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance). Any use of 01996 would begin the following day.

Often payer policy will define how many days are allowed for 01996, Dennis notes. If it is medically necessary to exceed the number of days outlined in the policy, your provider must document the reason postoperative pain management is still needed.