Top 10 Anesthesia Documentation Items to
ENSURE MAXIMUM COLLECTIONS
Billing for the specialty of anesthesia is somewhat of an art form. The key is for coders to know what to look for within the charting process, and to proactively communicate documentation trends to their respective practices. Listed below are ten common issues that, if not detected, can lead to significant lost revenue for practices.
1.
Accurate description of Surgical Procedure(s) performed
Although Anesthesia is billed with unique, time-based codes, such codes can quickly change when the surgeon modifies the planned procedure. Take, for example, a diagnostic knee arthroscopy that is converted to a medial meniscectomy. The anesthesia code for the latter procedure pays one additional unit per case, when documented.
For paper anesthesia records, this requires a quick recap with the surgical team at the conclusion of each case. For electronic records, the information is typically input by the surgical tech, but should still be verified for accuracy. Either way, it’s crucial that the surgical description not be populated before the procedure begins and never looked at again.
2.
Anesthesia Start Time
Per the ASA and CMS, time begins when the anesthesia provider is in personal attendance with the patient and is preparing the patient for induction.
This does not include the preanesthesia assessment, which is not separately billable. However, if you are in the holding area and administer an anxiolytic 5 minutes prior to entering the operating room, this is billable time. Also, patient transfers from the ICU to the OR (or vice versa) are to be included in your billable anesthesia minutes. The takeaway here – “OR in time” does not always reflect your true anesthesia start time, which may have begun earlier.
3.
Labor and Delivery Time
Unlike traditional surgical cases, labor time typically begins when the epidural is placed and ends when one of the following events occurs (whichever is last): baby delivery, placental delivery requiring anesthesia attendance, or episiotomy requiring anesthesia attendance.
The bottom line – delivery time is not always the true end time for these types of cases, when charted properly. Also worth noting are Labor to C-section cases. Make sure that you always chart both events, as it yields one additional base unit per case.
4.
Transesophageal Echocardiograms (TEE)
Many payers, including Medicare, will only pay for TEEs when an interpretation is documented by a physician (a certified Anesthesiologist or Cardiologist). Due to this requirement, it is recommended that all TEE probe placement procedures include a notation of “interpretation and report by Dr. X”. Although there is a code for TEE probe placement without a formal interpretation (93318), few insurers pay for it.
5.
Staffing Changes
When an intraoperative hand-off occurs between anesthesia providers, it is important to chart when the relief took place and who was involved. Failure to chart these changes can result in inaccurate concurrency ratios for medically directing practices and can skew provider productivity numbers.
6.
Invasive Monitoring Lines
Arterial Lines, Central Lines and Swan-Ganz catheters are billed as separate surgical procedures, along with the anesthetic. Documentation needs to show who physically placed each line and whether or not ultrasound guidance was utilized. Simply checking a box that the line was used during the case is not sufficient for billing purposes.
CVPs and Swans can be separately billed when there are “two separate sticks” documented, or when the Swan is placed at a later time. If the line is placed by a SRNA or Resident, documentation should state that the Anesthesiologist was physically present during the entire minor surgical procedure.
7.
Post-Op Pain Blocks
Acute pain blocks require 3 main documentation items: That the block was performed at the surgeon’s request, that its primary purpose was for post-op pain, and whether or not ultrasonic guidance was utilized.
In addition, it should be specified who placed the block and whether such placement occurred prior to or after induction. Physicians should steer clear of documentation that says “block used for pain and primary anesthetic”, as this does not clarify the block’s primary intent.
8.
Final Mode of Anesthesia
Similar to the planned surgical procedure that can change mid-stream, it is important to document the final anesthesia type on each record that you complete. For example, a planned MAC anesthetic that is converted to a General (defined as any loss of consciousness) should be clearly noted to avoid unnecessary denials.
For example, many insurance plans have restrictive coverage policies for MAC GI Endoscopy procedures, but allow payment for Propofol General anesthetics. Be vigilant to ensure that the final anesthesia type is accurate.
9.
“Shadowing” Providers
When a provider such as a SRNA is charted as being in the OR, but is there only for observation purposes, this should be noted. SRNAs and Residents have a 2 room physician oversight limit, but this is not the case if the SRNA is simply observing and has no clinical involvement in the case.
10.
Medical Direction
Each Care Team case involving both an Anesthesiologist and an Anesthetist should include documentation showing that all 7 of the TEFRA requirements were satisfied by the Anesthesiologist.
These are: ensuring the Anesthetist is qualified, participation in the preanesthesia assessment, presence at induction and emergence, frequent monitoring, remaining immediately available, and providing indicated post-anesthesia care.
This can be done via individual or global attestations and should be time-stamped. Requirements can also be shared by different Anesthesiologists within the same group. For groups who employ their CRNAs, it is appropriate to bill cases as “non medically directed” when these attestations are incomplete and payment is typically revenue neutral.
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.
