Anesthesia Coding Alert

Teach your team documentation secrets to get paid consistently

Before you submit a labor epidural claim, you need more than just the correct code--or you risk losing payment for your provider's services. Train your anesthesia team to document the following areas and prepare your claims for smooth sailing. Key 1: Explain the Services Provided Reporting a labor epidural begins with CPT's anesthesia codes for labor patients:

- CPT 01967--Neuraxial analgesia/anesthesia for planned vaginal delivery (this includes any repeat subarachnoid needle placement and drug injection and/or any necessary replacement of an epidural catheter during labor)

- +CPT 01968--Anesthesia for cesarean delivery following neuraxial labor analgesia/anesthesia (List separately in addition to code for primary procedure performed)

- +01969--Anesthesia for cesarean hysterectomy following neuraxial labor analgesia/anesthesia (List separately in addition to code for primary procedure performed). But reporting these codes alone isn't enough to satisfy carriers. The anesthesia provider should include other notes on the patient's record to explain the service more fully, make your coding more accurate and meet carrier requirements.

Example: A laboring patient comes to the hospital at 37 6/7 weeks- gestation. If the anesthesiologist notes that the case becomes a cesarean delivery but doesn't explain why, you don't have much documentation to support your claim for 01967 and 01968. Better documentation would include a note such as, -Failure to progress resulted in emergency c-section.-

Having more detailed notes from your providers means you-ll report an associated diagnosis such as 660.6x (Failed trial of labor, unspecified) instead of resorting to a general diagnosis such as 669.7x (Cesarean delivery, without mention of indication). Key 2: Document Who's Involved Multiple members of the anesthesia team sometimes become involved with labor patients, especially when cases cross shifts. Cover your coding bases by verifying that the anesthesia record clearly documents:

- Who performed the pre-operative exam

- Who actually inserted the epidural

- Who monitored the patient during labor

- Who removed the catheter following delivery. The easiest way to document these details is to use a template or some type of check boxes for the providers to mark--but that doesn't mean it's the best way to meet documentation guidelines.

-Anyone can check a box,- points out Kelly Dennis, CPC, ACS-AP, PMCC, owner of the consulting firm Perfect Office Solutions in Leesburg, Fla. -Having the providers- initials or signatures are more clear indications of who was actually involved in the case.-

-The best way to document a service and have proof of it is to write it out and sign it,- advises Barbara Johnson, CPC, MPC, president of Real Code Inc. in Moreno Valley, Calif. -If different physicians are involved in parts of the case (i.e., pre-op, placement and removal), then documentation should show each name/signature and [...]