03/26/2019 – Episiotomy Work Is Included In L&D Epidural Code

Question: A patient received an epidural during a vaginal delivery. Immediately after delivery, the patient was having bleeding so additional MAC anesthesia was given for episiotomy repair. Are these considered two separate billable procedures since the delivery took place under the epidural instead of MAC?

Answer: MAC is primarily used for sedation, although you don’t mention the level of sedation used for the episiotomy repair. With that being said, it appears you should report the initial anesthesia/original epidural during for labor and delivery with 01967 (Neuraxial labor analgesia/anesthesia for planned vaginal delivery (this includes any repeat subarachnoid needle placement and drug injection and/or any necessary replacement of an epidural catheter during labor).

According to coding guidelines, when a provider performs multiple surgical procedures during a single anesthetic administration, you report only the anesthesia code representing the most complex procedure (or higher level of units). You combine the time from all procedures and report in conjunction with the higher-level anesthesia code. In your scenario, you should report 01967 (5 base units) and not 00940 (Anesthesia for vaginal procedures (including biopsy of labia, vagina, cervix or endometrium); not otherwise specified) for the episiotomy (3 base units).

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