By: Hal Nelson, CANPC
MSN Vice President of Anesthesia Services
Having worked with hundreds of anesthesia practices over the years, I’ve been able to assemble a list of
common charting errors that cost groups money, in the form of insurance revenue. One of the most
common issues is the proper charting of anesthesia time. In this article, we’ll discuss anesthesia start
time, anesthesia end time, and everything in-between.
Background
The specialty of anesthesiology is paid using a hybrid methodology of time-based and ‘flat fee’ codes.
Time-based codes include all anesthetics, whose charge and payment amounts will vary, depending
upon the total number of minutes spent delivering anesthesia. ‘Flat fee’ codes are ancillary anesthesia
items, such as lines and blocks. These procedures are always priced the same, with insurance payments
varying by carrier and plan.
Anesthesia Start Time
Per the AMA and ASA, anesthesia start time begins when the anesthesia clinician begins preparing the
patient for induction of the anesthetic, either in the operating room or equivalent area. The takeaway
here is that billable time is not restricted to OR time only. In order to bill for pre-op time, you must
administer (and chart) sedation given in pre-op. It’s acceptable if vitals haven’t begun being charted yet.
You simply need a note in the anesthesia record, such as: ‘Versed administered preoperatively from
07:00-07:10; anesthesia personnel continuously present.’
Anesthesia End Time
Per the AMA and ASA, anesthesia end time occurs when the patient is stable and turned over to
recovery room personnel. Best practice is to have an anesthesia care transfer time box in your PACU
notes to corroborate your end time. Again, billable time is not limited to ‘in-room’ time only.
Anesthesia Discontinuous Time
Most anesthetics involve one or more anesthesia providers being continuously present with the patient
from case start to end. However, there are several examples where this doesn’t occur. For blocks and
lines placed in the OR, billers will need to compare placement time to induction time. If the line/block
was placed pre-induction, placement minutes need to be subtracted from billable anesthesia case
minutes, since you can’t be paid for an ancillary procedure and also bill for its placement time. It’s one
or the other.
If the line/block is placed post-induction, then no anesthesia time needs to be deducted. Another
example involves pre-op spinals used as part of the primary anesthetic. In this instance, you’ll likely have
two separate sets of start/stop times; one for the spinal placement and another for the anesthetic.
Simply sum the minutes and bill for total time. Bottom line: Billable anesthesia time does not need to be
continuous.
Labor and Delivery Time
Labor epidurals are unique in that you’re typically paid for management time and not ‘Time in
Attendance.’ Due to this fact, labors (CPT 01967) are excluded from concurrent case reporting. Start
time is the epidural insertion and end time is the latter of newborn delivery, placental delivery, or
perineal repair. Side note: For plans which pay you a labor case rate instead of using the standard (base
+ time units) x conversion factor, be sure to always set your fee at this exact amount. Failure to do so
will result in underpayments on quick labor and delivery cases, since insurance pays the lesser of your
billed charge or their case rate.
Patient Transport Time to/from ICU and CCU
You can bill for patient transport time, if you’re physically present with the patient and a note is charted
within the anesthesia record.
Rounding of Charted Anesthesia Time
Keep in mind that Cigna, Medicare, and United Healthcare all convert your total anesthesia minutes to
prorated or fractionalized time units. For this reason, start and end times should always be charted to
the exact minute, and not rounded to the closest ‘0’ or ‘5’ minute increment.
Time Charting and EMR Access Issues
Some EMRs are only located within ORs, which lends itself to potential underbilling. There are two
solutions here: Ask your facility’s EMR vendor to make the platform available in both pre-op and post-op
and (2) If this isn’t feasible, make sure that your start/stop times include these perioperative minutes.
Return to OR Time
Billing for ‘return to OR’ cases will vary, depending on whether there was a transfer of care or not. For
cases with no transfer of care to PACU, you simply bill for total time, which may involve updating your
anesthesia end time. If a transfer of care has occurred, the ‘return to OR’ is considered as a separate
case, requiring new start/end times.
Surgeon Delay Time
If you’re physically present with a patient and awaiting a delayed surgeon’s arrival, you can include this
time in your billable anesthesia minutes.
On-Call Labor Time
You cannot bill for labor epidural time if you’re not within the physical confines of the hospital. In other
words, being on call within 10 minutes of the facility does allow one to bill for anesthesia/analgesia
time.
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.
