Anesthesia Coding Alert

Question: I have a question about ob/gyn billing. If both the Certified Registered Nurse Anesthetist (CRNA) and the anesthesiologist sign the record, do I report the epidural with a medical direction modifier, or should the documentation state the anesthesiologist personally performed the procedure?

Kentucky Subscriber

Answer: You can only report the anesthesiologist personally performed the procedure if they personally performed the service. This is true for both obstetric and surgical cases. Although the Office of Inspector General (OIG) removed personally performed services from their workplan, they still expect modifiers to match the documentation.

In this case, if they have both signed the record, you will be looking for information to support medical direction. As there is not an induction or emergence period for a labor epidural, you will also look for other indications on the record, such as presence or involvement when the epidural catheter is placed or removed. Either the physician or the CRNA should document who placed the catheter. Sometimes, nursing staff will remove the catheter, so this may not be documented by the anesthesia department. Additionally, any interaction with the patient should be documented, as there are some policies that require contact with the patient to report face-to-face time.