Wiki Epidural forceps delivery

[cmacpc]

Need some help not sure how to code this one? Patient had epidural @ 10:48. Same day @ 17:35 patient ws taken to the OR f/possible C/S w/dx of Arrest of Labor, post dates.
Op rpt as follows: Adequate anesthesia acheived w/epidural combined w/MAC anesthesia. Low forceps applied to the baby' head w/o difficulty, while head was crowning rt mediolateral episiotomy was performed & baby delivered w/o difficulty.
During exploration it was noted that there was a 3-4 cm long LT lateral wall laceration. LT & RT mediolateral episiotomy repaired w/2-0 monocryl suture in the usual manner. It was noted patient was having uterine atony. One dose of Hmabate was given IM and the pt tolerated the procedure well.
Pt was taken to recovery for 2 hr observation due to the excess sedation with MAC anesthesia.

How would this be coded since patient had the previous epidural earlier then went to the OR and anesthesia was still there. Would I could the epesiotomy???

TIA

 

[Michele Hannon]

There are several ways to code a labor epidural:
1. base units + time (insertion thru delivery) subject to a reasonable cap
2. base units + face to face time with the patient (insertion, management of adverse events, dosing and attendance at forceps delivery) + one unit of time per hour
3. single fee
Keep in mind, that in the end, this was still a labor epidural for a vaginal delivery. You need to capture the operating room time (including episiotomy) until the patient was safely placed in the care of the recovery room staff.