Anesthesia Coding Alert

Question: How should I code an anesthesia consultation for post-spinal headache?


Mississippi Subscriber


Answer: Correct coding depends on whether the anesthesiologist only performed a consultation or actually administered the injection to treat the headache. It also depends on whether this is the anesthesiologist's first encounter with the patient. Double check the documentation and talk with the anesthesiologist to verify which type of encounter to report.

If he simply performed a consultation, he must meet CPT's documentation requirements before you can report the service (99231-99233, Subsequent hospital care, per day, for the evaluation and management of a patient). If the same physician performed the patient's initial consult prior to surgery, some coders believe this could qualify as a follow-up consult if the physician meets documentation requirements (99261, Follow-up inpatient consultation for an established patient).

If your anesthesiologist administered the post-spinal injection to treat the headache, only report 62273 (Injection, epidural, of blood or clot patch). Remember this is a flat-fee service, so you shouldn't report time units. Submit 349.0 (Reaction to spinal or lumbar puncture) as the diagnosis.