Anesthesia Coding Alert
Reader Questions:
Document Every Service, Even if it’s Bundled
Published on Tue Jul 12, 2022
Question: Does Medicare require us to include post-op notes for care following a labor epidural? Virginia Subscriber Answer: Yes, you always need to include documentation of every procedure and patient encounter to support the services rendered and included in your claim — even if the service is bundled with another service and not separately billable. In your scenario, the postoperative care is included in the epidural payment but is still part of the patient’s overall treatment and must be detailed in a post-op note.
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