Challenges facing anesthesia coders
by Judy A. Wilson, CPC, CPC-H, CPCO, CPC-P, CANPC, CPC-I, CMRS
An anesthesia provider faces plenty of challenges: cancelled anesthesia, failed medical direction, monitored anesthesia care, time issues, invasive line placement rules, and start/stop times.
Most anesthesiologists know when the anesthesia time starts and stops, but they are not always sure of how to handle relief time. Relief times must be documented and failure to do so could cause a compliance problem. An anesthesiologist cannot relieve a Certified Registered Nurse Anesthetist (CRNA) that he or she is medically directing. Best practice calls for the CRNA to relieve a CRNA and an MD to relieve an MD.
Correctly report time
To correctly report anesthesia time, coders need to bill for the services provided by the anesthesiologist who spent the longest time on the case. They also must be careful when rounding time up or down. Medicare wants start and stop time to be reported to the nearest minute. If high numbers of cases begin or end on the “5-minute mark,” that practice could become the proud winner of an audit.
So what is Medicare’s take on time and data for the average anesthesiologist who usually spends no more than seven minutes with a patient in post-anesthesia care unit (PACU) before signing off the case? If an auditor finds a larger percentage of PACU time to be more than the typical seven minutes, he or she may assume fraud unless the organization can prove otherwise.
Remember that CMS expects staff to chart vital signs and the record must match the reported start and stop times. If Medicare conducts an audit, it will disallow any anesthesia time of more than one unit (15 minutes) that exceeds charted vital signs. Therefore, it’s important that the physician document why he or she spent longer than the average turn over time with the patient.
CRNAs and anesthesiologists should only report the total anesthesia time for the sum of the continuous block of anesthesia. For example, if the anesthesiologist had to wait for the surgeon to start surgery he or she would document a stopped time for the waiting period and then indicate a start time when the surgeon started the case.
Coders should make sure that the CRNA or anesthesiologist documented the information so that an auditor can see the continuous and discontinuous periods of anesthesia.
Also make sure that the total anesthesia time adds up to the blocks of continuous time. Documenting discontinuous time is essential. CRNAs and anesthesiologists must document the actual start and stop in the appropriate areas and must check the discontinuous time box when appropriate. They should also document discontinuous time in the remark section with legible notes.
Here is an example of a good note for documenting discontinued time: 9:52 anesthesia out time, waiting on surgeon, 10:02 anesthesia in time.
Placement of multiple lumens
Anesthesiologists must understand that they will not receive separate payment for placing multiple lumens. The exception is when the anesthesiologist did a central venous pressure and a Swan-Ganz and there were two separate lines or two sticks. In order to bill for this, the anesthesiologist must document the line placements and the monitoring.
Anesthesiologists should never bill time for placement of post-operative block or invasive lines prior to the administration of the primary anesthetic for the surgery. These services need to be billed as a flat rate fee. On the other hand, after the administration of the primary anesthetic do not subtract time for the post-operative block or invasive lines.
Time spent placing lines
Is time spent on placing an invasive line or epidural catheter included in the anesthesia time? That will depend. Placement of blocks post surgery and before anesthesia induction or after anesthesia emergence should not be included in the anesthesia time regardless of the sedation and monitoring that is provided to the patient during the block placement. Blocks that occurs after induction and prior to emergence is not deducted from the reported anesthesia time. If the anesthesiologist administers sedation solely for placement of the block, do not include it in the reported anesthesia time.
Coders need to code arterial, central line, regional blocks, epidurals, etc., as separate procedures. These services are not included in the reported anesthesia time and are billed separately.
Coders also need to report pain management services in conjunction with an operative anesthesia service.
Documentation requirements for cancelled cases
Anesthesiologists have to know how to document cancelled cases so the coder will be able to code for it. If the procedure is cancelled before induction, coders should provide the correct evaluation and management code and give the reason why the case was cancelled (e.g., case cancelled due to equipment failure). If the procedure is cancelled after induction, coders should report the code with the appropriate modifier, -53 (discontinued procedure), -73 (procedures discontinued prior to anesthesia), or -74 (procedures discontinued after anesthesia administration or after the procedure has begun), plus time.
As most anesthesia coders are aware, many carriers do not accept these modifiers. Coders need to know which payers require modifiers and which ones will not accept them. If the payer does not accept a modifier, the physician can bill these cases using the correct anesthesia code with the full base units for the procedure that was scheduled, plus total time that is documented on the anesthesia record. Reason for the cancellation should also be clearly documented.
Additional grey areas
When billing for monitored anesthesia care (MAC), pay attention to medical necessity. Documentation is critical to support diagnoses and ensure reimbursement and compliance with a local coverage determination (LCD). Because LCDs differ from carrier to carrier and change rapidly, coders need o keep up with the LCDs. (Note that if a patient loses consciousness at any time it becomes a general anesthesia and no longer is consider MAC).
Medical direction is another grey area for anesthesiologists. Most know the seven steps of medical direction, but it becomes muddy because not all services are allowed during medical direction.
In essence, if an anesthesiologist is immediately available, he or she is allowed to address a medical emergency of a short duration in the immediate area. Unfortunately Medicare does not clearly define short duration so it’s up to each practice to decide what it considers is a short duration. CMS gives guidance on what constitutes immediately available and immediate area, but no clear cut answers. My recommendation is to use common sense. For example, an immediate area does not mean three to four floors up or out of the building. Organizations need to be consistent with policies on these areas and follow their Medicare provider’s guidelines. Never assume anything. Keep abreast of all the evolving rules that apply to your state for processing anesthesia.
Editor's Note: Judy Wilson has been an anesthesia medical coder/biller for more than 28 years. For the past 19 years, she has been the business administrator for Anesthesia Specialists, a group of nine cardiac anesthesiologists who practice at Sentara Heart Hospital. Judy started the Virginia Beach AAPC chapter and continues to be an active participant. She also teaches the Professional Medical Coding Curriculum (PMCC) at several locations in Tidewater, Va. In 2011, Judy was the treasurer for the AAPCCA Board of Directors. She has presented at several AAPC regional conferences and the national conference.