Anesthesia Coding Alert

Question: I’m coding for a case in which a patient was not a candidate for a labor epidural. The patient was placed on a remifentanil PCA (patient-controlled analgesia) and subsequently needed a Cesarean section. Because of the circumstances, my anesthesiologist was present for the entire case. I don’t think I can file with 01961 for C-section delivery only. What do you think?

Illinois Subscriber

Answer: Your question doesn’t indicate how long the patient was on the PCA, so we can’t provide a detailed answer. However, you can report 01961 (Anesthesia for cesarean delivery only) with the documented anesthesia time. PCA would not be reported as a separate anesthesia service.