OB Series Part 1: Understanding ASA’s Proposed Methods and Payer Requirements
November 2, 2023OB Series Part 3: Thorough Documentation necessary for coding deliveries
November 29, 2023Welcome to the second installment of our OB series, focusing on obstetric delivery codes for anesthesia as recommended by ASA and the related documentation considerations.
In part one of this series, the ASA Proposed Methods and Payer Requirements were explored. With those options in mind, let’s dive in to this installment addressing the OB delivery ASA code options and documentation considerations.
Choose the delivery method
While there are many different paths to the delivery of an infant, from a coding perspective they can be categorized into four options.
- Vaginal
- C-Section
- Vaginal following C-Section (VBAC)
- C-Section following vaginal attempt after C-Section (CVBAC)
This information is essential for the OB-GYN when reporting their portion of the delivery, but is assistive to the anesthesia coder as well when putting the pieces of coding together.
The anesthesiologist’s role
Next, the coder is tasked with determining the role of the anesthesia team.
- Was an epidural placed?
- Did the patient have a scheduled C-section?
- Did the patient labor, but complications required a C-Section?
The responses to these questions reflect options in the ASA code selection.
In the structure of electronic medical records (EMR), sometimes it is a challenge for the anesthesia provider to document labor and delivery, whether vaginal or c-section, as one event.
Seek complete documentation
As there are multiple outcomes once labor is initiated – delivery, conversion to c-section, adverse events, or even discharge – a coder cannot assume that delivery occurred from a labor record alone.
Likewise, a delivery record that only supports the type of delivery does not permit a coder to assume that the patient labored.
Often the coder is tasked with seeking documents outside of the anesthesia record to fill in these blanks. Remember, even if the labor and delivery (L&D) process crosses multiple dates, it is still a single event.
Utilizing complete documentation of L&D elements, from the first interaction the anesthesia team has with the mother until the encounter is complete, ensures that coders can capture the events accurately for the anesthesia service(s) performed.
As always, if you have any questions, please contact us. We are here to help.
For more on coding for labor and delivery, read our posts OB Series Part 1 and OB Series Part 3.