Anesthesia Coding Alert

Question: We have begun handling our anesthesia billing internally. The company that has been billing for us reported 99231 for postoperative visits when the anesthesiologist or CRNA saw inpatients on subsequent days after surgery but did not perform pump maintenance. Is this correct reporting?

Maryland Subscriber

Answer: The correct code for postoperative care depends on the service your anesthesiologist or CRNA provides. If they are visiting patients to check on catheters the provider placed for nerve blocks for post-op pain management, the correct code is 99231 (Subsequent hospital care, per day, for the evaluation and management of a patient …) as long as their documentation supports their level of service.

If they are visiting patients to follow up on epidural placements or pump checks, the correct code is 01996 (Daily hospital management of epidural or subarachnoid continuous drug administration). As the explanatory note in CPT^® states, “Report code 01996 for daily hospital management of continuous epidural or subarachnoid drug administration performed after insertion of an epidural or subarachnoid catheter.” The documentation requirements are not as stringent as a subsequent visit code, but should still reflect the follow up services provided to the patient.

Good to know: For normal rounding after a labor epidural delivery, no additional anesthesia charge is billed as routine post anesthesia/analgesia is included in the base value for the service. If the epidural is left in place and there is additional follow-up above and beyond the usual service, the service may be billed as documented.