Anesthesia Coding Alert

Question: Can you help us understand when to add the hysterectomy code +01969? We had a patient that had a normal delivery using 01967, and then had to go back to the operating room (OR) the next day for an emergency hysterectomy. Is that when we report the add-on code??

Florida Subscriber

Answer: The code descriptions and circumstances will help guide your coders to the correct code to report. As your patient had a normal delivery and returned to the OR the following day, you will report 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)) for the labor epidural and 01962 (Anesthesia for urgent hysterectomy following delivery) for the urgent hysterectomy following a delivery.

You should only report add-on code +01969 (Anesthesia for cesarean hysterectomy following neuraxial labor analgesia/ anesthesia (List separately in addition to code for primary procedure performed)) if the obstetrician performed a cesarean hysterectomy after the labor epidural and, typically, both services would be on the same anesthesia record. There is another coding option, 01963 (Anesthesia for cesarean hysterectomy without any labor analgesia/anesthesia care) that you would use to report a cesarean hysterectomy when there was not an associated labor analgesia/anesthesia service. However, neither 01963 nor the add-on +01969 are appropriate to document the scenario you are reporting.