Anesthesia Coding Alert

Question: I’d like some input for proper coding of anesthesia related to labor and delivery, particularly how to bill CRNA and medically directing anesthesiologist (MDA) charges. The case situation is that the mother started out with an epidural only under the CRNA with no medical direction. Then, due to failure to progress, the mother had a C-section. At that point the anesthesiologist became more active in the case and was present for the C-section along with the CRNA. All the requirements of billing using QK and QX are met for the C-section part of the day. How do I code the C-section since the plan of care and medical direction status changed? 

Pennsylvania Subscriber

Answer:  The correct codes are 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]) and +01968 (Anesthesia for cesarean delivery following neuraxial labor analgesia/anesthesia [List separately in addition to code for primary procedure performed]). 

You’ll need to get answers to several questions before attempting to append modifiers:  

• Was the anesthesiologist actually medically directing the CRNA during the labor epidural portion of the encounter? 
• How many CRNAs were supervised by the medically directing anesthesiologist (MDA) during the C-section? 
• If the MDA was present during the delivery, did the MDA perform the service or was he there only for monitoring and assistance?

The answers will depend on the type of anesthesia model your group uses, how many CRNAs were under the physician at the time, and if the physician was there. 

Presuming that there is only a single CRNA performing the labor epidural portion, not under any supervision of an anesthesiologist, then you would code with 01967 and modifier QZ (CRNA service: without medical direction by a physician). 

From what you state, the directing anesthesiologist was present for the delivery, making this case a medically directed case. For the anesthesiologist you would bill 01968-QY (Medical direction of one certified registered nurse anesthetist [CRNA] by an anesthesiologist) if there’s only the single CRNA being directed. If the anesthesiologist directed more than one CRNA, the code and modifier will be 01968-QK ((Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals). The CRNA in this situation would bill 01968-QX (CRNA service: with medical direction by a physician). 

Some payers want the entire case billed by the same provider from start to finish, but that’s not always realistic. Other payers, however, recognize that one provider might start the epidural while another may be present during the C-section. Some payer contracts even state that this situation is possible and that they will allow payment for it. 

It’s always best to refer to your contracts and/or payer policies in these scenarios. Then you should be able to find some definitive answers before submitting the claim.  

Additional tip: Keep in mind that not all insurance companies require medical direction modifiers.