Anesthesia Coding Alert

Question: Our physician administered an epidural for a vaginal delivery, followed immediately by additional MAC anesthesia for episiotomy repair due to bleeding. Can we bill the anesthesia as two separate procedures since one was an epidural and the other MAC?

Massachusetts Subscriber

Answer: Based on the information you share, it appears the initial anesthesia administered by epidural should be coded as 01967 (Neuraxial labor analgesia/anesthesia for planned vaginal delivery (this includes any repeat subarachnoid needle placement and drug injection and/or any necessary replacement of an epidural catheter during labor)). Although your provider administered MAC for the episiotomy repair, you are still coding for a single encounter based on your note that the repair took place immediately following the delivery. Because of this, you should only report a single anesthesia code for the higher based and more complicated procedure (01967 in this case). Depending on the method your practice uses to report labor epidural time, you may include the full amount of time in your time units calculation from epidural placement through the episiotomy repair.