Anesthesia Coding Alert

Question: I've received some charge sheets that have both "epidural" and "spinal" anesthesia circled during knee or hip replacements. Why are both types noted? Can we bill 62319 (Injection, including catheter placement, continuous infusion or intermittent bolus, not including neurolytic substances, with or without contrast [for either localization or epidurography], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or subarachnoid; lumbar, sacral [caudal]) with modifier -59 (Distinct procedural service) for the epidural with the spinal anesthesia? Virginia Subscriber Answer: The physician may have used both types of anesthesia during the procedure, which is why both are noted. This is a common technique in obstetrics (known as combined spinal epidural analgesia, or CSEA) and is gaining popularity in the operating room. In obstetrics, the spinal provides immediate pain relief, and the epidural is used during labor after the spinal analgesia wears off. The spinal and epidural are often administered at the same time.

The combination technique is sometimes used the same way in surgery. The spinal is used for the anesthetic, and the epidural is used for postoperative pain analgesia. Physicians often begin an epidural for post-op pain management during a surgical procedure while the patient is still under general anesthesia. This may be what's happening in your situation. Both types of anesthesia can be billed if the anesthesia provider did not use the epidural to deliver anesthesia during the procedure. When this is done, bill the surgical procedure with the corresponding diagnosis and the epidural as you suggest (but using 62318 [ cervical or thoracic] if appropriate instead of 62319). Appropriate diagnoses for the procedure include an applicable pain code plus V58.49 (Other specified aftercare following surgery) to show the carrier that this is postoperative pain management.

If the surgical procedure is not performed under general anesthesia, many practices do not bill for the post-op pain management on the same day. However, you can bill the next day's postoperative pain management with 99231 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: a problem focused interval history; a problem focused examination; medical decision making that is straightforward or of low complexity) using the same pain and post-op aftercare diagnoses if medical necessity is documented. The anesthesia agent can help you determine whether it was probably used for a spinal or epidural. Lidocaine and bupivacaine can be used for either type of delivery. Tetracaine is used for spinals, and 2-chloroprocaine is used for epidurals. Epidural delivery of narcotics, such as morphine sulfate or fentanyl, is sometimes used to manage post-op pain. Encourage the physician to document the record more clearly so coding [...]