Anesthesia Coding Alert

Question: I have a patient who had a labor epidural and ended up going to C-section. The insurance company paid for the epidural but will pay time only for the C-section and no base. They are saying that, because the patient had an epidural, the anesthesiologist already had an epidural in place and therefore should be paid for time only. I have not had this problem in the past, and we are not contracted with this insurance company, so it is not a matter of an agreement. Maybe I have billed this incorrectly, so I would appreciate any help you can give me.

Ohio Subscriber

Answer: Primary code 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)) and add-on code +01968 (Anesthesia for cesarean delivery following neuraxial labor analgesia/anesthesia (List separately in addition to code for primary procedure performed)) are the correct codes to report for an epidural for a planned vaginal delivery that converts to a C-section.

Both the American Society of Anesthesiologists (ASA) Relative Value Guide^® (RVG™) and Medicare assign 5 base units to 01967. But there is a difference for +01968. The ASA RVG™ assigns this code 3 base units, while Medicare assigns 2 base units.

Also keep in mind that some payers have their own reporting rules for add-on codes and may assign different base units.

Unfortunately, insurance idiosyncrasies are hard to understand without a specific obstetric anesthesia policy. If the insurance allowed fewer than 8 units, you may try to appeal. This appeal should include a reference to the ASA RVG™ assigning add-on code +01968 a base value of 3 units to allow for the additional risk and work involved.