Author: Tony Mira
Not all cases are created equal. Labor epidural services differ significantly from the more typical OR-based anesthesia cases when it comes to the rules for assessing and documenting time. To ensure anesthesia providers are up to speed on the requirements of labor epidural time documentation, this article is provided.
“I think it’s time.” The husband looks at his wife with a confused brow that eventually turns to wild-eyed panic. “You mean it’s that time,” he anxiously asks. “Yes,” she calmly replies. This is immediately followed by the customary rush to find the car keys and the classic ignoring of speed limits along the way to the hospital.
Preparing to bring a child into the world is a time of immense excitement mixed with a little terror. For the anesthesia provider, this time takes on a whole other meaning. Our purpose today is to continue our primer on anesthesia time. In this part, we will focus on labor epidural time.
A Different Animal
There are four broad categories of services performed by anesthesia providers: (a) anesthesia for procedures, (b) ancillary procedures (e.g., invasive lines, emergency intubations, pain blocks), (c) visits (e.g., rounds, consults), and (d) labor epidurals. Typically, time-based billing is generally associated with only the first and last of these service categories. When it comes to anesthesia cases that involve procedures in the operating room or equivalent area, the rules for documenting and billing time are consistent—irrespective of the type of procedure or surgery being performed. However, when an anesthesia provider is involved in a labor epidural, the time rules are a bit different.
To be perfectly frank, labor epidural services constitute a completely different animal from other anesthesia cases. In fact, CMS has questioned whether or not a labor epidural should even be considered an anesthesia service. After deliberating on this issue several years back, the agency eventually decided to leave it up to each facility to designate whether the labor epidural is to be deemed as anesthesia or analgesia. Another indication of the difference between labor epidural services and “regular” anesthesia cases is that placing a labor epidural is one of the acceptable exceptions to the medical direction rules. That is, it’s what you can do while medically directing, rather than a case that is medically directed.
An Array of Options
Given these differences, you would expect that time accounting for a labor epidural is going to diverge a bit from the normal anesthesia case, as well; and, in fact, that is exactly what we find. The Relative Value Guide (RVG), published by the American Society of Anesthesiologists (ASA), concedes that there is no national standard for billing labor epidural time. Accordingly, the RVG lists various options for capturing such time that a provider or group might adopt within their practice. The ASA did not mean this list to be exhaustive but rather representative of some of the more commonly used methodologies acceptable for labor epidural billing. They are as follows:
- Base units, plus time reported in minutes (insertion through delivery), subject to a reasonable cap. Delivery may include related services such as delivery of placenta or episiotomy/laceration repair.
- Base units, plus one unit per hour (time unit as defined by local standards and time reported in minutes) for neuraxial anesthesia service management plus direct contact time (insertion, management of adverse events, delivery, removal).
- Incremental time-based fees (e.g., 0<hrs, 2-6 hrs, >6 hrs).
- Single fee.
The option that we typically recommend involves the first methodology listed above, otherwise referred to as “stick to delivery subject to a reasonable cap,” in addition to billing the base units associated with the labor epidural code, 01967. Accordingly, where a payer does not already have different guidance in place for billing labor epidurals, the group should consider listing their epidural start time concurrent with the epidural placement time and listing their stop time concurrent with the time the infant is delivered. We at the billing office will bill time reflecting the total case minutes, up to a pre-determined, group-set, monetary or unit amount.
Delving into Delivery
According to the capped “stick to delivery” billing option, discussed above, the stop time is typically going to be the delivery of the infant. However, you will not always be present for this event. Even so, you may still list the infant delivery time as your case stop time. If you do not know the infant delivery time, we will attempt to determine this time from other hospital records.
With the first labor epidural billing option (capped stick to delivery), the above RVG excerpt goes on to state, “Delivery may include related services such as delivery of placenta or episiotomy/laceration repair.” The word “may” is inserted here for a reason. The statement does not say that “delivery includes,” but rather “delivery may include.” So, when can you list your labor epidural stop time to coincide with these post-delivery events? We reached out to the ASA on this matter and, based on their clarification, it would be appropriate to list a stop time for post-delivery events (e.g., delivery of placenta, episiotomy repair) if you are actually present for these events. So, if the baby is delivered at 1030 and the placenta is delivered at 11:00, and you are present with the patient for the latter, you can list a labor epidural stop time of 11:00, rather than 10:30. If you are not present for such post-delivery events, then your default stop time is the time the infant is delivered—even if you are not there for the baby’s arrival.
Some payers reimburse labor epidural services based on actual face time, which means the RVG billing methodologies listed hereinabove are no longer options from which you can choose. For these payers, you’ll need to know which definition of face time they utilize. Some payers may define this time as being at the patient’s bedside, while others may define it as simply being present in the labor and delivery suite. Knowing your payer rules becomes particularly important when you are managing multiple labor epidurals simultaneously within the labor and delivery suite.
Once you’ve determined the payer’s definition of face time, you will need to document on the labor epidural record (or equivalent record) your face time. Typically, this is done by marking the time chart on the vitals graph or alternatively listing your time blocks elsewhere on the record. For example, for payers who define face time as presence at the patient’s bedside, you will want to document the time you spent placing the epidural, the time you came in to check on the patient, time spent redosing, etc. Certain Medicaid plans will often pay labor epidural services based on face time. You will need to be aware if your patient is a beneficiary of one of these payers, so that your documentation can comport with their unique face-time requirements.