Anesthesia Coding Alert

Question: How should I code a single dose of DepoDur following surgery and follow-up days?

California Subscriber

Answer: Physicians administer a single epidural dose of DepoDur to the patient's lumbar region following major surgery. The physician or CRNA must monitor patients on DepoDur for at least 48 hours.
 
Report the initial injection with 62311 (Injection, single [not via indwelling catheter], 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]).

Reporting the follow-up days seems hard unless you understand the medication. One shot of DepoDur lasts two or three days, so your physician is monitoring the patient rather than administering additional pain medication. Because of this, you should not report 01996 (Daily hospital management of epidural or subarachnoid continuous drug administration) for the follow-up days, as some coders assume. Instead, report 99231 (Subsequent hospital care, per day, for the evaluation and management of a patient ...) for each day the physician visits.