What Considerations Do I Need To Make
When Billing for Anesthesia Services?
By: Hal Nelson, CANPC
First off, it takes an experienced team to keep pace with the demands of today’s complex healthcare market. MSN Healthcare Solutions has provided anesthesia billing services to groups for nearly 30 years, so we understand your challenges and want to ensure the right people are on your team, supported by the right technology to make things happen.
In this article we hope to explore and explain what considerations needs to be made when billing for anesthesia services.
Mode of Anesthesia
There are three main billing categories for anesthesia type:
- General: a case in which the patient loses consciousness at any time during the anesthesia event, regardless of airway access.
* most TIVA/Propofol cases qualify
- Regional: include epidurals, spinals and nerve blocks, when used as the primary anesthetic
- Monitored Anesthesia Care (MAC): “conscious sedation” or “twilight anesthesia”
It is important to designate the anesthesia type correctly, as some insurance plans have restrictive coverage for MAC anesthetics, since sedation can alternatively be provided by the surgeon.
For cases involving a general anesthetic with a post-op pain block, it is not necessary to indicate a “combined anesthesia technique”, if the block’s primary intent is for post-operative pain management and simply provides some adjunctive benefit to the primary anesthetic.
When the final mode of anesthesia is different from the planned mode, this too should be documented.
Physical Status Modifiers
Anesthesia patients are assigned a physical status modifier (1-6) during the pre-anesthesia assessment. This designation does not change intraoperatively, regardless of complications that may arise during the case.
Since many private insurance plans reimburse at a higher case rate for ASA 3 and above, it is important that all anesthesia providers within a group practice have a consistent understanding on the application of these modifiers.
Some payers also use such modifiers as a condition for payment on GI endoscopy procedures.
For more information, please visit the American Society of Anesthesiologists: ASA Physical Status Classification System article
Similar to physical status modifiers, qualifying circumstance codes are designed to show increased patient risk and are reimbursed separately by some private payers.
Qualifying circumstances include:
- extreme age (under age 1 or over 70)
- deliberate hypotension (requires documented request of surgeon)
- deliberate hypothermia
Of these, deliberate hypotension and emergency are the most commonly used.
An emergency is defined as existing when a delay in treatment would result in an increased risk to the patient’s morbidity/mortality. Examples include emergent appendectomies, open fractures, and laboring C-sections with documentation of fetal distress or non-reassured heart tones.
Time begins when the anesthesia provider begins preparing the patient for anesthesia and ends at “anesthesia care transfer”.
Clinical time spent in Pre-Op/PACU, as well as transfer time between ICU/OR, is billable.
In these scenarios, if vitals are not being taken, providers should chart the record noting the clinical event. For paper sites, start/stop times should be recorded at one-minute increments, without rounding.
The pre-anesthesia assessment is bundled into your anesthesia payment and should not be included as separately billable anesthesia minutes.
Discontinuous Anesthesia Time
Anesthesia providers may occasionally have instances where anesthesia time is “paused” during a case.
For example, the provider gives a sedative to the patient in pre-op holding, anticipating taking the patient to the OR. After 5 minutes, the case is delayed and the patient left with a RN, until such time that the case can resume. The anesthesia provider rejoins the patient shortly afterwards, and the case is completed.
In this scenario, both blocks of disjointed time are added together and billed as total anesthesia minutes.
Documentation should show multiple start and stops times, or at least specify the time period in which the anesthesia provider was not in direct personal attendance with the patient. Difficult IV starts requiring anesthesia involvement may also fit into this category.
Labor and Delivery Time
Time begins at epidural/spinal insertion time and ends at the latter of one of the following events: delivery time, placental delivery time, or episiotomy end time where the anesthesia provider is in attendance. Similar to anesthesia OR time, minutes should be exact and not rounded.
Intraoperative Handoffs (Relief)
All staffing changes during an anesthesia event should be clearly noted to include the providers involved and their respective start/stop times.
Billing companies typically report under the provider(s) with the greatest amount of time in the case, once concurrency is verified for all supervising physicians.
For “hybrid cases” that are part medically directed and part personally performed, Revenue cycle management vendors usually bill as medically directed, as instructed by many Medicare Administrative Contractors.
If an anesthesia provider (such as a SRNA) is in the OR for a case, but is simply shadowing a physician or CRNA without performing any clinical work, this should be noted on the legal medical record. Revenue cycle management firms will not input shadowing providers for billing purposes.
Physician oversight is limited to a 2-room maximum when working with Residents and/or Student Registered Nurse Anesthetists (SRNAs) on anesthesia cases.
Similarly, up to 2 concurrent SRNA cases can overseen by a single teaching CRNA without physician involvement, if facility bylaws permit.
For minor surgical procedures performed by the Resident or SRNA (i.e., invasive line placement), documentation must show that the physician was physically present during the entire minor surgical procedure. Anesthesiologists should use their standard teaching physician documentation for these cases.
In Accredited Teaching Hospitals, cases involving 1-2 residents will be billed as personally performed by the anesthesiologist and noted as a teaching service, in accordance with CMS guidelines.
Invasive Monitoring Lines
Arterial lines, CVP/Central lines and Swan-Ganz catheters are separately billable as surgical procedures.
Documentation should include which provider placed each line, whether placement time was before or after anesthesia induction, and if ultrasound guidance was utilized.
Both a CVP and a Swan can be separately billed if “separate sticks” are notated.
Transesophageal Echocardiography (TEE)
Billable TEE services include “probe placement only”, “formal interpretation and report only”, or the global service.
Documentation should always specify which service(s) the anesthesia provider performed.
For “probe placement only”, it is necessary to indicate the physician’s name who provided the interpretation and whether or not a formal report was generated.
Acute Pain Blocks
Pain blocks are separately billable, if documented as being requested by the surgeon for post-op analgesia.
Similar to invasive monitoring lines, documentation should indicate which provider placed each block, whether placement time was before or after anesthesia induction, and if ultrasound guidance was utilized.
More than one pain block can be billed, if medically necessary (i.e., femoral and sciatic nerve blocks). A combined spinal epidural (CSE) is considered to be a single procedure, and is typically billed as an anesthetic only.
Acute Pain Rounding
Beginning on post-op day (POD) one, pain rounds can be billed separately if supported by a pain progress note completed by the anesthesia provider. This includes the in-person daily management of continuous catheters, as well as pain rounds for non-catheter (Duramorph) patients.
The daily management of epidural code (01996) can be billed for as many days as deemed medically necessary, including the day the catheter is discontinued.
This is a calendar- based code, meaning that it does not require 24 hours of management time in order to bill.
Care team anesthesia groups employing a medical direction model should document the anesthesiologist’s completion of the 7 TEFRA criteria, in the form of individual or global attestations.
They are as follows:
Ensuring that the anesthetist is qualified (by way of signature)
Participation in pre-anesthesia assessment
Presence at induction (not applicable for MAC cases)
Presence at Emergence (not applicable for MAC cases)
Frequent monitoring (approximately once per hour)
Immediate availability throughout
Providing post-anesthesia care, as indicated
*Both induction and emergence are considered as clinical continuums, meaning that physician presence is required during at least some portion of these events. CMS does not define these terms.
Cases where an anesthesiologist is overseeing more than 4 concurrent anesthetist cases will be billed as medical supervision, as opposed to medical direction.
Unlike medical direction, where net payment is the same as a personally performed case, medically supervised cases pay the anesthesiologist only 3-4 total units, with the CRNA receiving their standard 50%.
*The billing term “supervision” (5+ cases) is not to be confused with the CMS Hospital Conditions of Participation term “supervision”, the latter of which which requires physician oversight (either by the surgeon or anesthesiologist) of CRNA services in non-opt out states.
Non Medical Direction
Care team anesthesia groups who (on a case by case basis) do not satisfy the medical direction criteria can elect to have such cases billed as non-medically directed, assuming that the practice employs their CRNAs.
Payment is typically the same as the personally performed anesthesia rate. Anesthesiology Assistants (AAs) cannot be billed independently and must be submitted as medically directed.
Hal Nelson, CANPC
has 30 years experience on both the payer and RCM side, with a focus in Anesthesia. He formerly worked as a senior claims approver at United Healthcare, as well as a compliance officer for multiple national billing companies. He has also taught the CPC coding curriculum collegiately in Atlanta. His broad based experience ensures that MSN clients will have a resource for documentation and billing issues. His past speaking engagements include ASA, MGMA, Dartmouth, and Johns Hopkins.
This educational guide was prepared as a tool to provide education for documentation and coding. It is not intended to affect clinical treatment patterns. The material provided is for informational purposes only. Efforts have been made to ensure the information within this document was accurate on the date of distribution. Reimbursement policies vary from insurer to insurer and the policies of the same payer may vary within different U.S. regions. All policies should be verified to ensure compliance. CPT® codes, descriptions and other data are copyright of the American Medical Association (or such other date of publication of CPT®).All Rights Reserved. CPT® is a registered trademark of the American Medical Association. Proprietary and confidential document. All rights reserved. No part of this document may be reproduced or used in any manner without the written permission of MSN Healthcare Solutions, LLC.