Anesthesia Coding Alert

Question: How should requests for daily postoperative pain management be documented?

North Dakota Subscriber

Answer: The surgeon’s request for an anesthesiologist or pain management specialist to administer a postoperative block for pain management should be in the operative report.

From an anesthesia standpoint, you should get a copy of the surgeon’s request for your own chart. Post-op pain management using a subarachnoid or epidural catheter in place that takes place the following day(s) after surgery should be documented by the anesthesiologist with 01996 (Daily hospital management of epidural or subarachnoid continuous drug administration). The visit notes should include the reason for the visit (chief complaint), as well as a brief history, physical examination (of the catheter site), and their medical decision (keep in place, adjust medications, etc.). If the catheter is not either epidural or subarachnoid, the documentation listed above will guide the coding to an appropriate evaluation and management code (99231 to 99233 range).