Anesthesia Coding Alert

Hint: You can bill 01996 only once per day.

Coders have long struggled with the documentation requirements for CPT^® code 01996 (Daily hospital management of epidural or subarachnoid continuous drug administration). Although the code descriptor seemed straightforward enough, coders weren’t always clear on what the service entailed or what type of documentation was expected for the “daily hospital management.”

Coders navigating anesthesia know that anesthesiologists aren’t necessarily instructed on documentation during medical school, so finding ways to communicate the requirements is important. One recommendation is to document the five Ws: who, what, when, where, and why.

Answer These Questions to Bolster Documentation

1. Who provided the service?

Often there is more than one anesthesia provider in a group and in order to bill the service, one must know who performed the service. It is also important to understand that by virtue of signing the documentation, the physician or qualified nonphysician anesthetist is attesting to the fact that everything contained in their signed documentation accurately describes and supports the service provided.

2. What service was provided?

The “what” is a coder’s clue for how medical services will be reported. In this case, documentation must support daily hospital management of an epidural or subarachnoid continuous drug administration. As patients may be sent home with an acute pain catheter, 01996 is automatically excluded as the patient is no longer in the hospital. This procedure is also limited to epidural and subarachnoid continuous catheters. As described by the New York School of Regional Anesthesia (NYSORA), “Before administering medications through the epidural catheter, subarachnoid, intravascular, and subdural placement should be ruled out” and coders may see terms such as “continuous catheter,” “bolus,” or “test dose” in the documentation for the initial catheter.

According to the Cleveland Clinic, epidural catheters are placed in the epidural space (between the dura mater of the spinal cord and bones of the vertebral column), whereas a subarachnoid catheter is placed on a deeper level (between the arachnoid mater and pia mater). Therefore, CPT^® 01996 is not reported for daily hospital management of other types of continuous catheters, such as CPT^® codes 64416 (Injection(s), anesthetic agent(s) and/or steroid; brachial plexus, continuous infusion by catheter (including catheter placement), including imaging guidance, when performed), 64446 ( … sciatic nerve … ), or 64448 (… femoral nerve …).

3. When was the service provided?

According to Chapter 2 of the National Correct Coding Initiative (NCCI) Revision Date (Medicare): 1/1/2025, “Management of epidural or subarachnoid drug administration (CPT code 01996) is separately payable on dates of service after surgery but not on the date of surgery.” Documentation of the date and time supports whether the patient was seen the following day and time spent with the patient. When time is documented during the visit, coders familiar with anesthesia coding rules understand the documented time should not be overlapping with any concurrent anesthesia cases.

4. Where was the service provided?

Because CPT^® 01996 cannot be reported until the day after surgery, these visits are typically performed in the patient’s room, rather than an operating room (OR) or post-anesthesia care unit (PACU). As the patient’s room is not near the OR or PACU, medically directing anesthesiologists with case oversight are usually not assigned to provide the daily management care for these patients.

5. Why was the service provided?

The NCCI, along with recommendations from the American Society of Anesthesiologists (ASA), provides explanations to help coders guide their clinical staff to proper documentation. The ASA’s “Statement on Reporting Postoperative Pain Procedures in Conjunction with Anesthesia” describes the conditions that apply to the initial catheter without outlining documentation expectations for CPT^® 01996. However, their recommendations for the initial catheter indicate as follows:

“One method for describing that the primary purpose for the block is to provide post-operative analgesia is to dictate or record details about the procedure in a separate document in the medical record from the anesthetic record. When documenting, it is important to discuss that:

1. “Some payers may require documentation that the surgeon requested the anesthesia team to participate in the provision of post-operative analgesia. Some other payers may require that the surgeon’s request be documented by both the surgeon and the anesthesiologist.
2. “The patient participated in the discussion regarding the most appropriate plan for post-operative analgesia.
3. “A distinct informed consent process must be provided for the post-operative pain management plan including providing the patient with specific information about the risks and benefits of the proposed therapy.”

Beware These Caveats

Having good initial documentation that follows the above ASA recommendations — along with the “five “Ws” of who, what, when, where, and why — are an excellent starting point. Your group may choose to create a template to help guide your clinical staff toward these five areas of documentation, although one must use caution not to lead or direct the documentation; it is also a good idea to leave room on the form for freehand notes. While there are some areas of consistency, documentation must be specific to each patient encounter and, regardless of how many encounters with the patient on a daily basis, this code is limited to once per day.

According to the NCCI Policy Manual, Chapter 2, using code 01996 to report this service is limited to once per postoperative day, regardless of the number of visits necessary to manage the catheter or whether an anesthesiologist or nonmedically directed CRNA reports the service. Additionally, “If the only service provided is management of epidural/subarachnoid drug administration, then an E&M service shall not be reported in addition to CPT code 01996.”

Understand These Parameters on Billing

Additional questions often asked are “How many days can we bill?” and “Can we bill the day the catheter is removed?”. These questions lead us back to the code itself, and coders should also be aware there are limitations that are usually defined by payer policies to determine how many days are covered.

When the catheter is placed, there is an expectation that it will also be removed, which is typically included in the work value of the code. There may be exceptions, depending on the documentation and circumstances. The number of days will depend on how the patient is responding to the treatment and what treatment is medically necessary for each particular patient.

Follow up may be limited to a specific number of days. For example, Regence Blue Cross and Blue Shield of Oregon limits coverage to three days by policy, although good documentation may allow one to exceed their policy limits. Knowing where resources are located and providing them to your clinical staff is half the battle! The other half is reviewing the documentation from time to time to ensure payers would consider services are well-documented and accurately represent the service provided.

Kelly D. Dennis, MBA, ACS-AN, CANPC, CHCA, CPMA, CPC, CPC-I, Contributing Writer