ASA Relative Value Guide (RVG) laid out four recommended options to charge calculation for a labor epidural service, which opened the flood gates for an almost endless number of variations as practices explored ways to optimize the revenue potential of this service. The RVG’s billing options for OB anesthesia, specifically in connection with a labor epidural, are as follows:
- Base units, plus minutes from insertion of catheter to delivery, subject to a reasonable cap.
- Base units, plus one unit per hour plus direct contact time.
- Incremental time-based fees.
- Flat fee.
Not only are there billing options as it concerns labor epidurals, there are coding options, as well, when it comes to OB anesthesia, generally. The CPT coding manual provides the following coding options, with the RVG listing base units that reflect a different care modality/scenario, per code:
- 01960 Anesthesia for vaginal delivery only, no mention of epidural (5 units)
- 01961 Anesthesia for cesarean section, no mention of epidural (7 units)
- 01967 Epidural for labor analgesia (5 units)
- 01968 Epidural for cesarean section after epidural (Add-on code worth 3 units*)
* Some insurances only pay 2 units.
An Assortment of Rules
Based on all these CPT coding and RVG billing options, the ABC billing system, First Anesthesia, now includes no less than 20 specific rules for OB billing. The key issue is the determination of time units. Historically, payer policies required the documentation of actual time spent with the patient, but increasingly anesthesia providers feel they should be paid for the time they are available. Diverse payer policies are a critical factor. The goal is to ensure appropriate payment. Usually, the Medicaid policies are the most specific, even though the rates are the lowest. Every state Medicaid policy for OB anesthesia is different.
Obviously, one of the major distinctions between surgical anesthesia and obstetric anesthesia is the fact that one provider may be managing multiple epidurals simultaneously. For most payers this is not an issue, but the rules for MediCal (Medicaid in California) take concurrency into consideration. The total units billed per hour cannot be more than four, no matter how many epidurals an anesthesiologist may be managing at one time even those that are not MediCal patients. This unique rule requires that we undertake a special review and calculation of concurrency for each labor epidural service, which in turn has necessitated some fairly complicated programming of our system.
Validating the accuracy of payments has become a significant challenge when it comes to OB anesthesia. Ironically, it is the lowest paying plans, mainly the Medicaid and Medicaid Managed Care plans, that require the most careful monitoring.
ABC eAlerts are timely updates and news affecting anesthesia and pain management providers.
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Complications of obstetric anesthesia are coded by pregnancy (O29), childbirth (O74) or puerperium (O94). Events beyond the 6-week puerperium are coded as non-obstetric. Complications of anesthesia are defined in ICD-10 as pulmonary, cardiac, CNS, toxic reaction to local anesthetic, spinal epidural, post-dural puncture headache (PDPH), other complications of spinal epidural, failure or difficult intubation of anesthesia, other complications of anesthesia, and unspecified complications of anesthesia.
Payment for anesthesia services rendered during labor is calculated differently from that for other anesthesia services. Payment is made according to the unit values listed on the tables below. The global unit values shown on the table shown on the table represent a combination of the base units for anesthesia rendered during labor and time units.
For each additional hour beyond three, one more unit will be allowed. Thus, four hours would be valued at 14 units, five hours at 15 units, six hours at 16 units and so on. A maximum number of units will not be imposed, as long as services are still being rendered.
prc.hmsa.com
