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Anesthesia Coding Alert

Reader Question:

Consider 01996 for Postoperative Pain Management Check

Question: Is it appropriate to bill 99231 when our anesthesiologist visits the patient at bedside to evaluate and document her postoperative intrathecal pain control? Our provider’s documentation includes notes for a problem focused history and a problem focused exam.

North Dakota Subscriber

Answer: Typically, the anesthesiologist or pain management specialist reports 01996 (Daily hospital management of epidural or subarachnoid continuous drug administration) for the post-op visit that takes place the day following the procedure. An E/M code such as 99231 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Medical decision making that is straightforward or of low complexity) is not appropriate.

Take note: If the anesthesiologist’s post-op pain management visit takes place on the same day as the procedure, it is not separately billable.  

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