How Documentation Choices Affect Base Units and Payment
By: Hal Nelson, CANPC
MSN Vice President of Anesthesia Services
When you closely examine the Ortho service line for anesthesia, you’ll see many charting nuances that can affect payment for your clinical services rendered. Take, for example, spinal fusion with segmental/non-segmental Instrumentation. When this detail is charted, it results in a base unit value of 13, as opposed to 8 (lumbar) or 10 (cervical/thoracic) without. The same unit values apply to other Ortho procedures involving 3+ vertebral bodies and two interspaces (i.e., Laminectomy, Laminotomy, Disc Replacement), so be sure to always document the precise levels involved. In this article, we’ll focus on Hip, Knee and Shoulder Arthroscopy and Arthroplasty procedures, and why there’s a chance you’re leaving money on the table through your current charting practices.
To fully understand the issue, we first need to focus on the anesthesia code options in play, along with their respective base unit values.
So, let’s say that you typically fill out the procedural section of your anesthesia record based on the scheduled surgery (or perhaps, this is auto-populated from your EMR). Hip, Knee, and Shoulder ‘Arthroscopy’ and ‘Arthroplasty’ descriptors alone are not sufficient, as they do not specify the surgical component of the former or the ‘partial’ vs. ‘total’ categorization the latter.
Best practice for paper sites is to have a ‘billing timeout’ at the end of each case. If an arthroscopy or arthroplasty was performed, be sure to add the right keywords to prevent delays in billing and underpayments. Yes, your biller can pend such cases and pull the surgeon’s op report to confirm, but this is not an efficient process. If you use an electronic anesthesia record or charge capture application, ask if this can be a ‘hard stop’, requiring the clinician to select requisite verbiage to close out the record.
In conclusion, a good billing firm should be asking for clarification on diagnostic vs. surgical arthroscopy, as well as partial vs. total arthroplasty, for every case submitted where charting was incomplete. If these procedural descriptions are not being questioned with proactive feedback supplied to your group, you may want to look at other billing options for 2026.
Definition of segmental instrumentation
- At least three fixation points: The construct must have fixation at the top and bottom ends of the segment and at least one additional point in between.
- Multiple attachment points: This allows for more stability compared to non-segmental instrumentation, which uses fewer attachment points.
- Example: A rod with screws at both the superior and inferior vertebral bodies and at least one screw on an interposing vertebral body would be considered segmental.
Definition of non-segmental instrumentation
- Definition: Spinal fixation where the implant is attached to the spine at only two points, typically the proximal and distal ends of the construct.
- Example: A rod that spans multiple vertebrae but is only fixed at the very top (e.g., L1) and the very bottom (e.g., L5).
Hal has 30+ years of experience on both the payor 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 anesthesia billing companies. His broad-based experience ensures that MSN clients have a resource for documentation and billing issues. His past speaking engagements include ASA, MGMA, Dartmouth, and Johns Hopkins.
