READER QUESTIONS:
Rely on 01967 for Some C-Sections
Published on Sun Aug 21, 2005
Question: The anesthesiologist saw a patient for cesarean section due to failure to progress. The chart does not mention a labor epidural or a catheter already in place. How do I code the case?
Washington Subscriber
Answer: Coding for this case hinges on the documentation you are holding. Even though "failure to progress" sounds as if the patient tried normal labor first, the attempt at normal labor is not documented. Considering this - and because you also have no documentation of a catheter - your best option is to code with 01961 (Anesthesia for cesarean delivery only).
If you had documentation of a catheter, you instead would report 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]), with add-on code +01968 (Anesthesia for cesarean delivery following neuraxial labor analgesia/anesthesia [List separately in addition to code for primary procedure performed]). Some coders recommend you also include 660.6x (Failed trial of labor, unspecified) as the diagnosis code on the claim. Add the correct fifth digit of 0, 1 or 3 to describe the current episode of care.