Anesthesia Coding Alert

Question: Our anesthesiologist began an epidural for a labor patient and periodically monitored her for several hours. He removed the epidural and she was transported to another hospital, where she eventually delivered (31 weeks gestation). How should I code our anesthesiologist's work?


California Subscriber

Answer: Begin with 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]), which is 5 base units. Append modifier 53 (Discontinued procedure) to indicate that the physician discontinued use of the epidural and include supporting documentation to explain the case.

Also submit diagnosis 644.03 (Threatened premature labor; antepartum condition or complication).

Providers have several options for reporting anesthesia time for laboring epidural patients, so it's important to know the carrier's policy beforehand. For example, some carriers require that you only report the actual face-to-face time the anesthesia provider spent with the patient; other carriers may have policies directing you to report the physician's time as 1 unit for each hour the epidural is in place.