Anesthesia Coding Alert

Question: Our anesthesiologist administered spinal anesthesia for a cesarean section and administered an intrathecal morphine injection. How should we code each part of the case?

Utah Subscriber

Answer: Report 01961 (Anesthesia for cesarean delivery only) for the delivery. You cannot bill separately for the intrathecal injection because your physician administered it with the c-section anesthesia. You can, however, include the time your physician spent with the injection in the total procedure time.

How it could change: You can sometimes bill the delivery anesthesia and postoperative pain management separately, depending on the situation. For example, if your physician administers general anesthesia during the delivery and uses spinal anesthesia primarily for postoperative pain management (instead of anesthetic delivery during the procedure), you can report both services. Ensure the documentation supports the additional postoperative pain management service.