How to Effectively Prevent “Charge Slippage” in Anesthesia Billing

doctor sitting at desk doing paperwork, outsourced medical billing concept

How to Effectively Prevent "Charge Slippage"

in Anesthesia Billing

By: Hal Nelson, CANPC
MSN Vice President, Anesthesiology Services

Outsourced professional billing is common for facility-based practices, such as Anesthesia. Third- party vendors assuming this revenue cycle management role typically do a fine job in submitting and collecting on most of your OR encounters.

However, how do you know that all of your clinical work is making its way to a claim form? You’d be surprised to learn how many billers don’t have the proper reconciliation processes in place to ensure that claim line-items are being submitted for everything that you do. This article is intended to describe common scenarios where billable events are missed.

OR Schedule to Case Reconciliation

If your billing company doesn’t receive a copy of the facility’s final surgical schedule that includes all add-on cases, something is wrong. Billers have to access this information, in order to know which cases need to be submitted to insurance. Having a final schedule also prevents cancelled cases from being billed out in error.

Out of OR procedures

This is where a lot of the charge slippage lies. Unlike OR cases which have a schedule to reconcile to, non-anesthetic perioperative services do not. Procedural notes for difficult IV starts, epidural blood patches, and invasive monitoring lines placed in ICU all need to make their way to your billing company to be paid. The data mapping for these services is often missed by the facility EMR team, who focus more on operative encounters.

Acute Pain Blocks and Invasive Monitoring Lines

When anesthesia practices chart these procedures, documentation is sometimes saved in a different module within the EMR than the anesthesia record. This creates the possibility of the anesthetic being billed without these ancillary charges, if the billing company doesn’t have the proper check and balance system in place. The solution is to have a check box on your anesthesia record which references the block or line, so that billers are aware of their existence and can retrieve the note through other means, prior to billing the case out.

Ultrasound Guidance

Most practices that use ultrasound do so on all line and block procedures, as a standard of care. Since this is a separately billable service, it’s important that your charting process include a reference to ultrasound being used and whether the image was archived in a retrievable format or not.

TEE interpretative Services

For cardiac practices that are credentialed to provide TEE interpretations, the diagnostic report generated is often separate and distinct from the anesthesia record. Similar to lines and blocks, this creates the potential for missed charges. Make sure that all TEE documentation is “pushed” to your billing company daily from wherever it’s housed. If you’re not on an EMR, make reference to the TEE interpretation in a consistent location on your anesthesia record. (i.e., Diagnostic TEE interpretation documented by Dr. Smith and archived to PACS).

Unscheduled Labors and Labor to C-Section cases

Unscheduled labors won’t be on an OB schedule. This means that you’ll need to make sure that your billing company is receiving a daily birthing log from the facility to retrospectively reconcile to.

Labor to C-Section cases can also be problematic, since there are often two different anesthesia providers involved in each component. Complicating matters is the fact that “Labor to Cs” are billed with two separate line items on a claim form; one for the labor (01967) and one for the Cesarean delivery (01968). To make sure that you bill accurately without the need for a corrected claim later, it’s best to incorporate a check box on your labor record to notate when the case is converted to a C-Section.

In the end, it’s all a matter of logistics. As the philosophical question was once posed by Mann and Twiss, “When a tree falls in a lonely forest, does it make a sound?” Similarly, when a clinical event occurs, does it end up being detected and ultimately billed? The answer to both questions is the same: Only if someone is there to hear it.

Hal Nelson, Vice President Anesthesiology Services


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.