Anesthesia Coding Alert

Question: Our doctors are doing DepoDur^® injections, which are intrathecal morphine extended-release injections that last 48 hours post-op. They are doing these preoperatively mainly for total hip and knee replacements. The doctors want to charge an inpatient consult code along with the injection, which is being done for post-op pain control only and is not the mode of anesthesia for the procedure. Would the consult be bundled because the consult, injection, and procedure are all being done on the same date of service? They are doing a pre-op H&P on the patient prior to surgery, which I know is bundled into the procedure. Are they allowed to charge the post-op pain management code 01996 following the surgery?

Georgia Subscriber

Answer: Most likely, you will be able to code the DepoDur^® injection and procedure anesthesia separately, but not the consult or 01996 (Daily hospital management of epidural or subarachnoid continuous drug administration, for subsequent day(s)).

Injection: DepoDur® is a single-shot injection given for postoperative pain relief and follows the guidelines for acute post-op pain management. The service must be requested by the surgeon, preferably in writing or with orders. Because you’ve mentioned the anesthesiologist gives the injection preoperatively, the documentation should be clear the injection was separate from anesthesia provided for the surgery. The services should be well documented either within the anesthesia record or in a separate procedure or progress note, as well as an indication of the time. (Find more documentation tips in “Code Correctly for Surgery With Post-Op Block” in Anesthesia Coding Alert, Volume 24, Number 12).

Consult: You are correct that you don’t report a visit or consult separately for this type of service, as it is part of the preanesthesia assessment.

Follow-up: Code 01996 applies only to an indwelling catheter, so you should not report this code for subsequent visits in this case. If a subsequent visit is warranted, there should be sufficient documentation to support billing a follow-up evaluation and management (E/M) visit.