Anesthesia Coding Alert

Question: One of our private insurers previously processed claims for labor epidurals with a time cap of 300 minutes without incident (the insurer would cap the payment at the 300 minute mark when applicable). The payer recently began rejecting any claims that exceeded the time cap rather than simply processing payment at the 300 minute cap. When we asked the reason, the person I spoke with said we should submit the claim with a modifier when the labor epidural exceeds the time cap.

This raises several questions for me. Which modifier would we append to the labor anesthesia code? Or is there a more appropriate way to submit claims such as these? Should we reduce the time on the claim to the cap limit to avoid denials?

Wisconsin Subscriber

Answer:  Anesthesia coding for labor and delivery gets complicated because there are several approaches that practices can take. As you probably know, sometimes the way you bill L&D anesthesia depends on the payer. 

Normally when a payer sets a cap for L&D charges, that’s the maximum amount of time you can bill for anesthesia/epidural care for that patient. If a case goes over that time limit, the anesthesiologist doesn’t get paid. It looks like this situation might be different since the payer is requesting a modifier with the claim. Your best option probably is modifier 22 (Increased procedural services) because that can sometimes help account for the extra time involved in a procedure. Verify with the payer that modifier 22 is the one they want on claims for these longer cases, because there’s a small chance they might want modifier 23 (Unusual anesthesia) instead.

Documentation: Verify that the documentation from your providers supports the substantial additional work and the reason for the extra time (increased intensity, technical difficulty, severity of the patient’s condition, etc.). Even if your provider isn’t being paid for L&D services beyond 300 minutes, always include the full, correct amount of procedure time on the claim. Reducing the claim time to 300 minutes or below in order to get paid may be considered fraudulent.