Anesthesia Coding Alert

Hint: It’s not your typical post-op management

If your physicians enjoy using different pain management techniques, you’ve probably run across some procedures involving Duramorph rounding, but opinions on how to correctly code the service vary.

Understand the Duramorph Difference 

Duramorph -- also known as Astramorph or preservative-free morphine -- is a systemic narcotic analgesic administered through a spinal or epidural catheter, says Tonia Raley, CPC, claims processing manager for Medical Information Systems in Phoenix. Physicians rely on Duramorph to manage pain in patients who do not respond to non-narcotic analgesics.
 
“Duramorph provides an extended period of pain relief without the loss of sensory, motor or sympathetic function,” says Cynthia Mulkey, marketing manager for anesthesia and consulting at Per-Se Technologies in Atlanta. A single dose of Duramorph can relieve the patient’s pain for 12 to 24 hours.
 
Anesthesia providers often use Duramorph for pain relief following a patient’s cesarean section. Administering Duramorph differs from a standard epidural or spinal catheter in several ways:
 
• Physicians administer Duramorph as a single-shot injection or through a catheter they plan to remove, not as a continuous epidural or spinal catheter.
 
• One dose of Duramorph is usually sufficient for pain relief, instead of re-administering doses every few hours.
 
• The timing for Duramorph administration is trickier than with other pain management techniques.
 
• Physicians often mix Duramorph with the drugs given spinally for a cesarean section. If your anesthesiologist uses this technique, he might list Duramorph on the anesthesia record with other medications administered spinally.
 
• If your anesthesiologist administers Duramorph epidurally, he gives it separately through the patient’s epidural catheter after the obstetrician clamps the umbilical cord. The epidural dose of Duramorph can be up to 25 times greater than the spinal dose. 
 
The anesthesiologist does not leave a catheter in when he uses Duramorph epidurally. Instead, he waits until the obstetrician clamps the umbilical cord to minimize any effect the drug might have on the infant. Then he administers the dose of Duramorph either through an existing epidural catheter or by an injection into the intrathecal space, Mulkey says.
 
When administering Duramorph, the anesthesiologist uses the same technique (epidural or spinal) as during the cesarean section.
 
Technique Dictates Your Coding

When you code this type of care, remember that the original anesthetic includes the patient’s first day of postoperative pain management -- that is, the code you reported for the labor and delivery, such as 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 epidural catheter during labor); and +01968, Anesthesia for cesarean delivery following neuraxial labor analgesia/anesthesia (list separately in addition to code for primary procedure performed).
 
Duramorph questions arise on the following day, when you can code separately for the postoperative pain management.
 
Code 01996 question: You often report postoperative pain management with 01996 (Daily hospital management of epidural or subarachnoid continuous drug administration). Some coders are tempted to submit 01996 for Duramorph, but Mulkey and Raley say this is wrong.
 
“You use 01996 to report daily hospital management for continuous drug administration,” Raley says. “That doesn’t apply in this situation because the physician administers Duramorph right before the catheter is removed. It’s not continuous  drug administration.”
 
“Since Duramorph is a single injection and the physician removes the catheter, there’s no management of a catheter,” Mulkey says. That’s one more reason 01996 is inappropriate for Duramorph.

Look to E/M for Best Code

So what should you report for Duramorph use? Raley and Mulkey both recommend E/M code 99231 (Subsequent hospital care, per day, for the evaluation and management of a patient ...).
 
Before automatically submitting 99231, remember that you must have sufficient documentation to support the code. Reporting 99231 means you have documentation for at least two of these three key components:
 
• a problem-focused interval history
 
• a problem-focused examination
 
• straightforward or low-complexity medical decisionmaking.

“The biggest issue is not getting the progress notes to support 99231,” Mulkey says. Submitting a copy of the progress notes with your claim can help ensure smoother processing.
 
E/M roadblock: Some coders say their carriers won’t pay for an E/M service the day after a procedure. If you run into this situation, consider appending modifier 24 (Unrelated E/M service by the same physician during a postoperative period) to your claim and include complete documentation for the visit.
 
Final caution: Duramorph provides effective pain relief for patients, but isn’t without its risks. The potential risk of respiratory distress is one of Duramorph’s serious side effects. Because of this, patients using Duramorph must be kept in a fully equipped and staffed observation unit for 12 to 24 hours after administration.