Anesthesia Coding Alert

Question: My CRNA (unsupervised) administered anesthesia for a bladder suspension for 625.6, Stress incontinence, female. The CRNA is also charging for post-op pain management with 62310 (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; cervical or thoracic). What is an appropriate diagnosis for the pain management?

Illinois Subscriber

Answer: Coding should be based on documentation or the operative report because physicians sometimes perform procedures with a different approach or technique. Code 62310 is for a single shot, not using a catheter, and you should use this code if you administer only one injection for the post-op pain. When the patient needs more involved post-op pain management, the anesthesia provider would generally place a catheter after the surgery and leave it in for a few days. Therefore, 62319 would be more appropriate if the CRNA places a continuous caudal anesthetic. You should add modifier -59 (Distinct procedural service) to the procedure code to distinguish it as a separate service from the procedure's anesthesia. Appropriate diagnoses for the pain management include 729.2 (Other disorders of soft tissues; neuralgia, neuritis, and radiculitis, unspecified) or V58.49 (Other specified aftercare following surgery). Code 788.9 (Other symptoms involving urinary system) could be an appropriate diagnosis for the initial bladder pain.

The procedure you describe does not require postoperative neuraxial anesthesia (the postoperative pain is usually not too bad). The CRNA may have used spinal anesthesia during the operation. If he or she mixed an opioid with the spinal (which is often done with this procedure), that may be why the CRNA wants to use 62310. However, most carriers will not pay for this because the CRNA used the one-shot spinal for the anesthesia.