Anesthesia Coding Alert

Question: What are the latest documentation requirements for reporting daily hospital management of epidural administration?

Massachusetts Subscriber

Answer: Code 01996 (Daily hospital management of epidural or subarachnoid continuous drug administration) applies when the anesthesia provider starts an additional infusion or bolus in a previously placed epidural catheter. Patients typically undergo this type of administration for a two-day intrathecal pump trial or an epidural infusion procedure.

NCCI stance: According to the National Correct Coding Initiative (NCCI) coding manual, "Management of epidural or subarachnoid drug administration (CPT code 01996) is separately payable on dates of service subsequent to surgery but not on the date of surgery. If the only service provided is management of epidural/subarachnoid drug administration, then an evaluation and management service should not be reported in addition to CPT® code 01996. Payment for management of epidural/subarachnoid drug administration is limited to one unit of service per postoperative day regardless of the number of visits necessary to manage the catheter per postoperative day (CPT® definition). While an anesthesiologist or non-medically directed CRNA may be able to report this service, only one payment will be made per day."

CPT® Assistant further clarifies that you should only report 01996 for epidural or subarachnoid administration. Specifically, the guidelines explain, "Currently, there is no specific CPT®　code for 'daily' management of the peripheral or plexus nerve catheter. It is not appropriate to report code 01996 as this is specific to epidural catheters. Carrier-specific guidelines may also apply if daily catheter management or injection is performed during the immediate postoperative period of another procedure or service."

Notation: Ask your providers to document their daily management of the epidural in the patient's progress notes. Having specific notes will support coding 01996 for each day.