Anesthesia Coding Alert

Question: What documentation requirements exist for daily epidural management?

Maine Subscriber

Answer: Several guidelines help you report postoperative pain management appropriately.

First, determine whether the physician placed an epidural for pain relief (patient-controlled epidural anesthesia, PCEA) or if the patient has patient-controlled anesthesia (PCA). If it's a PCA, use 99231 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: a problem-focused interval history, a problem-focused examination, medical decision-making that is straightforward or of low complexity).

If the physician places a PCEA on the day of the procedure, report it with 01996 (Daily hospital management of epidural or subarachnoid continuous drug administration). Only use 01996 when the anesthesia provider administers periodic injections into the epidural space through an indwelling epidural catheter that was already in place from the initial procedure.

Link 01996 with whatever ICD-9 code describes the condition being treated (such as 789.07, Abdominal pain; generalized; or 724.2, Lumbago, for back pain).

If the reason for daily management is not a covered diagnosis, the provider must thoroughly document the medical necessity and rationale for providing the service. Getting a written request from the surgeon for postoperative pain management helps distinguish it from anesthesia during the procedure. Some carriers only require a general diagnosis such as V58.49 (Encounter for other and unspecified procedures and aftercare; other specified aftercare following surgery).

Under normal circumstances, you do not bill any other service (including E/M codes) with 01996. The only exception is if the anesthesia provider renders a separately identifiable service on the same day. In that case, report the appropriate procedure code with modifier -59 (Distinct procedural service).