Anesthesia Coding Alert

Question: Our anesthesiologist placed a thoracic epidural preoperatively with the intention of using it for post-op pain control. According to the anesthesia record, the epidural was not used during the procedure and was not part of the anesthetic for the surgery (bowel resection). Because the patient experienced significant post-op hypotension and did not complain of significant pain for the first several days post-op, the epidural was never used and was discontinued two days post operatively because of the patient's continued hypotension. In this case, even though anesthesia saw the patient and wrote daily post-op notes, can we bill for daily management since the epidural was in place but never used? Or can we only bill for initial placement since the intent was to use it for post-op pain control, but it was never used because of the unforeseen patient hypotension?

Minnesota Subscriber

Answer: If the anesthesiologist did not monitor the epidural's use, then you cannot bill for daily postoperative management. If, however, the anesthesiologist saw the patient and there was medical necessity you might be able to bill 99231 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Medical decision making that is straightforward or of low complexity...).