Advanced Search

Anesthesia Coding Alert

Reader Questions:

Include Details for Post-Op Epidural

Published on Thu Sep 09, 2004

Question: Should I code daily management of a post-operative epidural differently if a CRNA performs it? What other details should I include?

Vermont Subscriber Answer: You should code the service the same, regardless of whether a CRNA or anesthesiologist performs it. If you treat a Medicare patient, be sure to include the correct modifier indicating the physician's role - probably modifier -QZ (CRNA service: without medical direction by a physician). The base code for epidural management is 01996 (Daily hospital management of epidural or subarachnoid continuous drug administration), at three base units (though this is only for follow-up days, not the day the CRNA places the catheter).
 
List the postoperative diagnosis as the primary diagnosis (usually the site of pain) and include V58.49 (Other specified aftercare following surgery) as the secondary diagnosis. Also, be sure to report type of service (TOS) 01 (Medical service) instead of the usual TOS 07 (Anesthesia service). Some carriers might also request that you note "Daily management of continuous epidural drug administration" in Box 19 of the CMS-1500 form.
You’ve reached your limit of free articles. Already a subscriber? Log in.
Not a subscriber? Subscribe today to continue reading this article. Plus, you’ll get:
  • Simple explanations of current healthcare regulations and payer programs
  • Real-world reporting scenarios solved by our expert coders
  • Industry news, such as MAC and RAC activities, the OIG Work Plan, and CERT reports
  • Instant access to every article ever published in your eNewsletter
  • 6 annual AAPC-approved CEUs*
  • The latest updates for CPT®, ICD-10-CM, HCPCS Level II, NCCI edits, modifiers, compliance, technology, practice management, and more
*CEUs available with select eNewsletters.

Other Articles in this issue of

Anesthesia Coding Alert

View All