Anesthesia Coding Alert

Question: Is it appropriate to use CPT 01996 (Daily hospital management of epidural or subarachnoid continuous drug administration) for a PCA (patient-controlled analgesia) pump postoperatively? If this isn't correct, what should I report?

Kansas Subscriber

Answer: Coding for PCA depends on how the analgesia is administered. If the physician inserts an epidural for post-op pain management, report the service with 01996. Do not report 01996, however, if it is an intravenous PCA. Many carriers don't pay for the PCA, so some groups handle subsequent hospital days by documenting PCA care as well as a patient visit and coding it with the appropriate choice from 99231-99233 (various components associated with Subsequent hospital care, per day, for the evaluation and management of a patient).