Anesthesia Coding Alert

Question: My physician provides anesthesia for a surgical procedure, and the surgeon asks my physician to consult the same patient for postoperative epidural infusion for pain management for post-op pain. Is this consult billable? Do I add modifier 25? What kind of documentation is needed to bill the pain consult?

New Jersey Subscriber

Answer: Did you bill for the placement of an epidural for this patient? If yes, then do not bill for a consult. If not, then you may bill a consultation service only if there is clear documentation of the surgeon's request for your physician's opinion and a written report of the opinion in the shared chart. If this is the case, then bill the appropriate inpatient consultation code (99251-99255) along with modifier 25 (Significant, separately  identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

A pain consult should be a written report stating the patient's chief complaint(s). Your physician will indicate medical history, family history, review of systems, the physical examination performed and an assessment by the doctor of the patient's diagnosis, and a plan of action. If the placement of an epidural is done, then bill only for that. For example, use 62319 (Injection, including catheter placement, continuous infusion or intermittent bolus, 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]), and include any follow up days.

Do not bill for a consult in addition to the placement of an epidural. If the consult is all that is done with no procedure performed, then bill the appropriate E/M coded for a consultation.