Anesthesia Coding Alert

Question: One of my doctors started a labor epidural, but the patient went home because of false labor. Should I still report 59409 (Vaginal delivery only [with or without episiotomy and/or forceps]) or 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])? Would I append modifier -53 (Discontinued procedure) because the delivery didn't happen?

Washington Subscriber
 
Answer: Using 01967 indicates that an actual delivery took place. Instead of reporting 01967 with modifier -53, report 62319 (Injection, including catheter placement, continuous infusion or intermittent bolus, not including neurolytic substances, with or without contrast [for either localization or epidurography], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or subarachnoid; lumbar, sacral [caudal]) with diagnosis 644.13 (Other threatened labor; antepartum condition or complication). This leaves you clear for 01967 when the delivery occurs, especially if the carrier has a limit of one delivery per patient every nine months.

 - You Be the Coder and Reader Questions were answered by Mary Klein, CPC, an anesthesia coder with Panhandle Medical Services Inc., in Pensacola, Fla.