ICD 10 Coding Alert

Question: A 27-year-old patient who is 40 weeks pregnant presented to the emergency room and, on evaluation, was noted to be contracting every six minutes with discomfort during the contractions. She was transferred to a delivery room, and anesthesia was called to place a labor epidural catheter for a full-term, uncomplicated delivery. The epidural was placed by the anesthesiologist at 12:21 a.m., and a baby girl was delivered at 3:21 a.m. The case was personally performed.

The surgeon was called away to another delivery and returned to perform a tubal ligation for elective sterilization with the anesthesiologist and CRNA from 7:21 a.m. to 8:36 a.m. The doctor was overseeing three cases during this time frame.

The patient has UnitedHealthcare insurance. What anesthesia, surgical, and diagnosis codes should be reported for this case, including time and modifiers?

AAPC Forum Participant

Answer: United Healthcare (UHC) addresses this scenario in its anesthesia policy.

For the labor epidural by the anesthesiologist, submit ASA code 01967 (Neuraxial labor analgesia/anesthesia for planned vaginal delivery …) with modifier AA (Anesthesia services performed personally by anesthesiologist) appended. The total anesthesia time for this case is 3 hours or 180 minutes.

Diagnosis roundup 1: The diagnosis for the initial case is coded with O80 (Encounter for full-term uncomplicated delivery).

According to UHC’s policy, the second case is considered a separate encounter. For the tubal ligation following delivery by a certified registered nurse anesthetist (CRNA) under the direction of the anesthesiologist overseeing three cases, use 00851 (Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; tubal ligation/transection) with the following modifiers appended:

• QK (Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals)
• QX (Crna service: with medical direction by a physician)
• XE (Separate encounter …)

Modifier XE indicates that the tubal ligation occurred during a separate encounter. If the payer doesn’t accept X{EPSU} modifiers, then apply 59 (Distinct procedural service). Anesthesia time for case two is 1 hour and15 minutes, or 75 minutes.

Diagnosis roundup 2: Report Z30.2 (Encounter for sterilization) as the diagnosis for the tubal ligation. Make sure to associate it with 00851 on the claim.