Anesthesia Coding Alert

Question: Our anesthesiologist attempted a patient's labor epidural three times. Anesthesia time began at 21:45 when the anesthesiologist examined the patient and prepared for the epidural. The anesthesiologist discontinued the procedure at 22:00 because the patient was fully dilated; she delivered vaginally. How should I report the attempted epidural?

Arizona Subscriber

Answer: Coders differ in their opinions on how to report this case. Because this is an obstetrical case, some coders recommend reporting 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 appending modifier -53 (Discontinued procedure).

Other coders disagree with this approach because the patient never received neuraxial anesthesia. Instead, they recommend that you report 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]) with modifier -53.

Sometimes fostering good patient relations is the best route to follow. Considering this - and considering that the case only represents 15 minutes of the anesthesiologist's time - a third option is to write off the time and not bill the patient for failed analgesia.

Discuss each of these options with the physician to determine which is most appropriate in this case.