Anesthesia Coding Alert

Question: How should I code postoperative management when the CRNA's notes read, "Post-op pain management x 2 days, 4/9 and 4/10/03"?

Michigan Subscriber

Answer: Report an appropriate pain code (such as 789.07, Abdominal pain; generalized; or 724.2, Lumbago, for back pain) and V58.49 (Other specified aftercare following surgery) to justify post-op pain management. Next, determine whether the physician placed an epidural (patient-controlled epidural anesthesia, PCEA) for pain relief or if the patient has a patient-controlled anesthesia (PCA) IV in place. 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 problemfocused interval history, a problem-focused examination, medical decision-making that is straightforward or of low complexity).

The physician might place a PCEA on the day of the procedure. If so, report 01996 (Daily hospital management of epidural or subarachnoid continuous drug administration) for each day the PCEA is used.

The CRNA's notes hopefully have more details than you included with your question, so the documentation will meet carrier guidelines. If you live in a state that does not cover CRNAs under nurse-practitioner rules, be sure a physician involved in the case co-signed the documentation so the services can be billed.