Anesthesia Coding Alert

Question: The anesthesiologist administered an epidural during a vaginal delivery. He followed immediately afterwards with additional MAC anesthesia for episiotomy repair due to bleeding. Can we bill the anesthesia as two separate procedures since the delivery took place under epidural instead of MAC?

Tennessee Subscriber

Answer: MAC (monitored anesthesia care) is primarily used for sedation, although you don’t mention the level of sedation used for the episiotomy repair. That being said, it appears that you should report the initial anesthesia/original epidural during for labor and delivery with 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)).

According to coding guidelines, when a provider performs multiple surgical procedures during a single anesthetic administration, you report only the anesthesia code representing the most complex procedure (or higher level of units). You combine the time from all procedures and report in conjunction with the higher-level anesthesia code. In your scenario, you should report 01967 (5 base units) and not 00940 (Anesthesia for vaginal procedures (including biopsy of labia, vagina, cervix or endometrium); not otherwise specified) for the episiotomy (3 base units).