Anesthesia Coding Alert

Question: Our anesthesiologist administers Duramorph injections for post-op pain following a cesarean section with spinal anesthesia or an epidural (when a vaginal delivery was originally planned). Can we code the Duramorph separately?


New Mexico Subscriber

Answer: The anesthesiologist usually administers Duramorph in the spinal anesthesia or before removing the epidural catheter from a c-section. CPT does not include a code for Duramorph, so coders have different opinions regarding whether to report it.

Many coders say you should not separately code the Duramorph injection because the physician administers it during the procedure's anesthesia. Others say you might be able to report 01996 (Daily hospital management of epidural or subarachnoid continuous drug administration) or 99231 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: a problem- focused interval history; a problem-focused examination; medical decision-making that is straightforward or of low complexity). Before coding it as either of these, verify the carrier's stance on reporting Duramorph and be sure the physician's notes fulfill documentation requirements.