Anesthesia Coding Alert

Question: We placed an epidural for labor. The patient delivered vaginally with uterine involution. The patient was taken to the OR for an exploratory laparoscopy (EX LAP) and reversion of uterine involution. Labor time was from 2010 to 0150 on the OB floor, and the EX LAP was 0150 to 0242 in OR. Our practice bills for face-to-face for labor, so how can I calculate the time for labor? And how should I code for the EX LAP?

Montana Subscriber

Answer: Always code for anesthesia using the highest base plus total time. You did not have a time lapse between the two services, so you should bill the highest base value. This is 00840 (Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; not otherwise specified) with a base 6 value, so you can bill it with the total applicable time for both procedures.

Keep in mind: Always remember to match the patient's correct diagnosis with the procedure code.

Don't forget: If your carrier requires face-to-face time for the labor epidural, you should only count the documented face-to-face time for that portion.

For example: If the epidural took 15 minutes to place and the physician documented presence with the patient for 60 minutes, add 75 minutes to the time for the EX LAP (52 minutes), and bill 127 minutes.

Remember to use the actual record to determine the time for the labor epidural.

Tip: Depending on the software system your practice uses, you may have to manipulate the start and/or stop time to capture the actual billable time. If you do this, make sure you leave detailed notes in the patient's account that will explain the variance.