Anesthesia Coding Alert

Question: I have a case in which a patient was not a candidate for a labor epidural. The patient was placed on a remifentanil PCA (patient-controlled analgesia) and subsequently needed a cesarean section. My anesthesiologist was present for the entire case because of the patient’s circumstance. I don’t think I can use 01961. What do you recommend?

South Dakota Subscriber

Answer: You are correct in thinking that reporting 01961 (Anesthesia for cesarean delivery only) is incorrect since this case involves more than the delivery. In fact, you should not bill anything for your anesthesiologist’s involvement with the patient. Are you certain the patient did not have any type of anesthesia service including monitoring for the C-Section? It would be highly unusual to have a patient provide their own PCA during this type of delivery. My advice is to ask for additional information from the anesthesia provider.

Explanation: When a doctor orders an IV med there is nothing billable to the physician. Ordering treatment is part of a physician’s job and is included in their care of the patient. In addition, a PCA is patient-controlled analgesia through an IV. The medication is brought to the patient care area in a cartridge that a nurse inserts into the IV pump and programs. The process does not require a doctor to be physically involved at the patient’s bedside so if no anesthesia service was actually provided, no anesthesia billing would apply.