Anesthesia Coding Alert

Question: Labor epidurals are so common, but it seems like our practice is always getting different opinions from our billing agency or carriers on which codes to use when. Can you offer any suggestions for how we can deal with this situation?

Maryland Subscriber

Answer: Anyone who is familiar with labor and delivery situations knows that no two deliveries are exactly alike. That may be why there are so many questions about the best way to code for epidurals used during labor, and why its important to know what each carrier you work with wants.

First of all, know that youre not alone. Its not uncommon for a doctors office to want to bill one code for a procedure and the billing agency to want to use another one instead. For example, the practice may prefer to bill labor epidurals for cesarean section patients with code 00857 (neuraxial analgesia/anesthesia for labor ending in a cesarean delivery [includes any repeat subarachnoid needle placement and drug injection and/or any necessary replacement of an epidural catheter during labor]). The billing group they work with may prefer to code it as 59514 (cesarean delivery only).

Whatever code your billing agency prefers, it is important for you to work with the agency to determine the best codes. Discuss why you think a particular code is best for a particular situation and decide from there. The most important thing is to report the procedure with the most accurate code that truly represents what was done. Then if more than one code fits the situation, use the code(s) that maximize reimbursement.

The code you use for labor epidurals also depends on the carrier and the circumstances. Most carriers accept any labor and delivery-related codes in CPT 2000, but some may have their own set of codes for labor epidurals that may not coincide with Medicare, American Society of Anesthesiologists (ASA) or CPT codes. Blue Cross/Blue Shield (BC/BS) is one example of this situation. BC/BS of Colorado used to have their own codes for labor epidurals. If you submitted a claim with CPT or ASA codes, they would transfer your code to theirs before reimbursing you. It didnt slow things down too much, but sometimes its best to just call the carrier and ask which code they want so you can get paid appropriately for it.

The first factor to consider when filing for labor epidural reimbursement is whether the baby is delivered vaginally or by cesarean section. Talk with your local carrier to determine which codes they think are best for particular situations, but any of the following codes may be accepted.

If labor and delivery progress with little or no complications, code 59409 (vaginal delivery only [with or without episiotomy and/or forceps]) may be used. For vaginal deliveries using epidural or other anesthesia, code 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]) or code 00955 (neuraxial analgesia/anesthesia for labor ending in a vaginal delivery [includes any repeat subarachnoid needle placement and drug injection and/or any necessary replacement of an epidural catheter during labor]) may be accepted by the carrier.

Many practices previously used code 62279 to report continuous labor epidurals. It is important to remember that this code was deleted from CPT 2000. The new code 62319 as defined above should be used in its place, and applies to both vaginal and cesarean deliveries.

Several CPT codes are also available for anesthesiologists to use to report cesarean deliveries. Many anesthesiologists use code 59514 (cesarean delivery only), a surgical code for this type of delivery. However, some anesthesia groups have found that it is easier to get reimbursement when they do not use surgical codes for the delivery. If the anesthesiologist, surgeon and obstetrician are all reporting the same code for the delivery, you may find yourself bumping up against the other specialists claims. Some carriers may say the procedure has already been paid for by the time they receive your paperwork, and deny your claim. Many anesthesia practices simply avoid using surgical codes whenever possible to help eliminate confusion. If you have this problem, you may want to file claims with anesthesia codes 00850 (anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; cesarean section) and 00857 whenever carriers will accept them.

The second factor for consideration is how time units associated with the delivery should be reported. Like the procedure code itself, how time units can be charged can depend on the patients carrier. For example, the BC/BS anesthesia manual states that codes 00857 and 00955 are global epidural procedures and are not based on time units for pricing. Instead, an anesthesiologist charges a flat rate for placing the epidural catheter since he or she is not present during the entire labor.

In addition, some carriers such as BC/BS also allow use of the HCPCS code S4850 when appropriate. S codes are temporary non-Medicare codes, and are not listed in the HCPCS book. The S codes usage varies from state to state; this code is still in effect in states such as Alabama and may be used for labor epidurals that last more than four hours. Check with your local carrier to verify its use in your area.

If only general anesthesia is performed, BC/BSs guide states that time units may be billed for codes such as 59400 (routine obstetric care including antepartum care, vaginal delivery [with or without episiotomy, and/or forceps] and postpartum care) or code 59510 (routine obstetric care including antepartum care, cesarean delivery, and postpartum care), beginning with induction into general anesthesia.

Some carriers will pay a billed fee for labor epidurals up to a certain point, then require additional documentation to pay for amounts over that point. Others pay a maximum of time units without additional documentation. Still others pay reduced time units, because they assume that the anesthesiologist checked on the patient only every half-hour or so.

Even though carriers may have guidelines for you to follow, theyre often old. The way the codes are set up now, its hard to know whether to use surgical or maternity codes, anesthesia codes or nervous system codes. When you add that to the fact that many of the carrier guidelines seem to contradict themselves, it can be very confusing. Your best bet is to know your local guidelines and follow them the best you can. And it always helps to know the carrier youre dealing with so you can work with them to get claims through the system.