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Coding Conundrum for Labor Epidurals

April 24, 2024

BY KELLY DENNIS, MBA, ACS-AN, CANPC, CHCA, CPMA, CPC, CPC-I, Perfect Office Solutions, Inc., Leesburg, FL

Coders often struggle with new or unique scenarios when it comes to reporting labor epidural services. It is important to communicate with your coders and billers to ensure compliant billing. For example, the following questions recently came through my inbox. 

Question: Would it be appropriate to use code 01960 to code for a vaginal delivery under nitrous oxide? 

Response: According to the Health Evidence Review Commission (HERC), “Nitrous oxide is a non-flammable, tasteless, odorless gas that is self administered on demand by laboring women through a mouthpiece or facemask (Collins, Starr, Bishop, Baysiner, 2012; Klomp et al., 2012).” While you may find resources recommending reporting 01960, the American Society of Anesthesiologists® (ASA) has not changed their position from reporting an unlisted anesthesia code for nitrous oxide since 2016. Code 01960 does not apply since the patient did not receive “analgesia/ anesthesia care” for the vaginal delivery. According to the ASA, a vaginal delivery under nitrous oxide should be reported with the unlisted code, 01999.

Coding tip! Unlisted codes require extra documentation. Include all relevant procedure notes and anesthesia records, as well as a listed code with a similar relative value. This helps the claims processor determine whether to allow and how much payment to allow!

Question: An epidural started on day one and ended on the third day. The patient labored for three days and did not deliver. The surgeon is billing 59856 due to fetal demise and that code crosses to an anesthesia code 01966, which is not the service we provided. Can I report 01967? The patient did not deliver vaginally, and I am not sure what ASA code to use for this since it was over 72 hours. 

Response: Even though the surgeon is reporting 59856, which crosswalks to anesthesia code 01966, your code will not match the surgeon in this case.  Your anesthesia provider placed an epidural catheter (code 01967), which does not require the patient to deliver.  Per the code description, “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.” The code is for planned delivery and the patient labored for three days before surgical intervention. Since the labor epidural was used as the method of anesthesia, your dilemma is in reporting the time of 72 hours.  If you follow one of the ASA’s recommendations for billing, as noted in the resource provided, there will be a cap on the charge. You still report the date and time span as documented.  Based on the unique circumstances, the payer may ask for documentation, and you want it to match the information being provided on the claim. Keep in mind the payer may also limit or restrict the amount of time spent for 01967.

Coding tip! Keep a close eye on your labor epidural charges and payments. Per the ASA, charges should “reasonably reflect the costs of providing labor anesthesia services as well as the intensity and time involved in performing and monitoring any neuraxial labor anesthesia service.” Payments may vary based on flat rates or caps by some payers. Know what your payers expect in your geographical location!

Question: We use a care team approach. If the anesthesiologist and a second certified registered nurse anesthetist (CRNA) were not present for the epidural and did not document their presence at the Cesarean section (C-Section), I am not sure how to bill this. We look for documentation from the medical doctor (MD) for the pre-anesthesia evaluation, anesthesia plan, a post-anesthesia evaluation and attesting to presence in order to bill as medically directed for a labor and delivery case. If any one of these are not documented by the physician, do we bill for only the CRNA as medical direction was not met? 

Response: Whether the labor epidural is one MD/CRNA care team and the C-Section is the same MD with a different CRNA or not, the medically directing anesthesiologist will document participation.  They should have already performed a pre-anesthesia exam and evaluation and prescribed the plan for the epidural.  These steps do not need to be met again for the C-Section.  This covers steps one and two (See Cigna resource linked at the end of this article). Moving forward to a C-Section may be a demanding aspect of the case, depending on the circumstances, and the medically directing anesthesiologists may document his or her presence, as applicable.   As epidural is a regional anesthesia, there is not an “induction” or “emergence” as with general anesthesia. Documenting presence and participation (such as present for placement of the epidural or placing the epidural catheter) would be true for both the epidural and C-Section, although case checks for an epidural are sporadic.  Interestingly, the monitoring at frequent intervals indicates “general anesthetic” and this is not a general anesthesia.  Clinical judgments are made by the medically directing anesthesiologist for each patient, and this covers steps three and five. 

Steps four and six indicate that no specific documentation is required.  These are a “given,” meaning these steps are expected for every single patient under the care of the anesthesia care team.

Step seven will be related to both the epidural and the C-Section, as there is not an expectation these are separated for post-anesthesia care requirements.  The anesthesia care team will transfer care of this patient to the PACU just once.

Coding tip! Each record should stand on its own for compliance purposes. If the steps of medical direction are not documented, payer guidance is referenced as Coronis understands policies differ. In any case, modifiers reported on the claim form should match the documentation! Otherwise, it may not be considered a “clean claim.”

For full details on the CIGNA resources, please click HERE.

Kelly D. Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I has over 40 years of experience in anesthesia coding and billing and has been speaking about anesthesia issues nationally since 2002. She has a master’s degree in business administration, is a certified auditor, coder and instructor through the American Academy of Professional Coders. Kelly is an Advanced Coding Specialist through the Board of Medical Specialty Coding and served as lead advisor for their anesthesia board. Kelly also serves as a practice management and reimbursement consultant for the American Society of Anesthesiologists. She is a certified healthcare auditor and has owned her own company, specializing in anesthesia consulting, Perfect Office Solutions, Inc., since November 2001. She can be reached at


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