Anesthesia Coding Alert

Question: Our anesthesia providers do rounds on patients following delivery to check on the epidural or spinal that they placed. We normally bill 99231 for the service. Is this correct, or is the care part of the global period?

South Carolina Subscriber

Answer: Because you are reporting an anesthesia provider’s service, the correct code is 01996 (Daily hospital management of epidural or subarachnoid continuous drug administration). The explanatory note in CPT^® further clarifies it with the note, “Report code 01996 for daily hospital management of continuous epidural or subarachnoid drug administration performed after insertion of an epidural or subarachnoid catheter.”

Code 99231 (Subsequent hospital care, per day, for the evaluation and management of a patient …) does represent subsequent hospital care, which might seem appropriate in this situation. However, 99231 is an evaluation and management (E/M) code so usually applies to specialties other than anesthesia.

Tip: For normal rounding after a labor epidural delivery, no additional anesthesia charge is billed as routine post anesthesia/analgesia is included in the base value for the service. If the epidural is left in place and there is additional follow-up above and beyond the usual service, the service may be billed as documented.