Anesthesia Coding Alert

Question: I am hoping you can answer a question about billing anesthesia for ob-gyn. I know that the anesthesiologist is not restricted to the number of patients that they can see for labor and delivery. My question is: when a patient has to go to surgery for a c-section, is the anesthesiologist still medically directing the Certified Registered Nurse Anesthetist (CRNA)? Does medical direction apply in this case? I am really not sure just how to bill for ob-gyn anesthesia since this is all new to me.

Kentucky subscriber

Answer: Even seasoned coders can get confused by all the various methods for billing labor epidural and requirements for medical direction! The best place to start in Kentucky is with your local payers. Check to see if they publish policy, which may limit the number of cases or define how you will bill for the labor epidural services. For example, Kentucky Medicaid pays a flat fee for labor epidural and does not appear to limit the number of concurrent cases, according to their latest fee schedule, published in 2023. However, other states, such as California and New Jersey, have limitations on the number of concurrent cases one physician can oversee for labor epidurals.

The next consideration is how far geographically the ob-gyn area is from the other cases that are being medically directed. Although labor epidural cases are listed as an exception in the CMS policy, which many payers follow, a medically directing anesthesiologist must be available to manage the medically directed cases to meet all the requirements published by the Center for Medicare & Medicaid Services (CMS) if you are billing Medicare.

The American Society of Anesthesiologist (ASA) also offer guidance through their statements and guidelines. According to the ASA’s “Definition of ‘Immediately Available’ When Medically Directing,” “A medically directing anesthesiologist is immediately available if s/he is in physical proximity that allows the anesthesiologist to re-establish direct contact with the patient to meet medical needs and any urgent or emergent clinical problems. These responsibilities may also be met through coordination among anesthesiologists of the same group or department.”

Physicians should document all transfers of care for both risk management and patient quality of care.