Anesthesia Coding Alert

Question: Our anesthesiologist says he performed a c-section with tubal ligation PCEA (patient-controlled epidural analgesia). CPT includes a code for a cesarean hysterectomy, but I don't see anything for a c-section tubal ligation. How should I report it?

Maine Subscriber

Answer: The physician did not perform a hysterectomy, so you cannot report 01963 (Anesthesia for cesarean hysterectomy without any labor analgesia/ anesthesia care). CPT does not have a code to report when the surgeon performs a tubal ligation through the c-section entry, so he will submit the procedures as separate codes with the appropriate modifiers.
 
Your anesthesia charge will be based on the higher-based procedure of the two with the total time for both procedures. Because of this, report 01961 (Anesthesia for cesarean delivery only) at 7 base units instead of 00851 (Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; tubal ligation/
transaction) at 6 base units, plus time.
 
Some coders might initially recommend 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 +01968 (Anesthesia for cesarean delivery following neuraxial labor analgesia/anesthesia [list separately in addition to code for primary procedure performed]), but you indicated that the c-section and tubal ligation were planned, so you wouldn't report 01967/01968 for this case.