Wiki C section Post op

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aal

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I hope someone can help me with this. We have some c sections and are having conflicting information over what to code for the post op day. (99231 or 01996)

I have single shot epidural before c-section. The catheter was removed after the C-section.

I have continuous epidural and the catheter was removed after c-section.

I have single shot spinal with nothing about a catheter.

What CPT/ASA codes would you use for the epidural, spinal and post op follow up day for an Anesthesia practice?

Thank you in advance.
 
For the C-section anesthesia you would use 01961 if it's a C-section alone. Otherwise use 01967 (labor) + 01968 (C-section). A lot depends on your payer so you should find out how they want this billed.

As far as post operative pain control goes, if you have an epidural catheter placed (that stays in for more than one calendar day) and the anesthesiologist sees the patient on the post op day you should bill 01996 for the management. If you're billing this, make sure you have a progress note showing the patient's pain scores and medical decision making for each post op day.

We generally don't bill for post op follow up as we find that providers don't truly provide a qualifying E/M service on the post op day. If yours are, they need to meet the requirements in CPT for 99231. Which states that you must have 2 of these 3 components: A problem focused history, problem focused exam and medical decision making of straightforward or low complexity.
 
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