Billers typically do well with Operating Room (OR) Anesthesia Case Reconciliation. As long as they receive a final surgical schedule, to include add-on cases (and exclude cases where conscious sedation is provided by surgical staff), it’s just a matter of pulling missing demos and anesthesia records from the facility portal. Although there may be a slight delay in claims submission, the cases will ultimately make their way to an insurer for payment consideration. But what about Out-of-OR (OOR) cases and procedures?
What Counts as an Out-of-OR (OOR) Case?
First, let’s define what an OOR case or procedure is. An OOR anesthesia case is one not performed in a standard operating room, but rather, a perioperative service location. Such service lines include EP, Eyes, GI, Radiology, etc. Since they’re still anesthesia cases, they will have a schedule to reconcile from, just not the same one used for the Operating Rooms. It’s important to understand this when onboarding a hospital-based anesthesia client, as these disparate service locations will need to be considered for all billing-related interfaces. If they’re overlooked, expect your case volume to be disproportionately low.
There are also OOR procedures to consider, which are not anesthesia cases. These are stand-alone clinical services that may not be linked to a particular anesthesia event. They include difficult IV starts, emergency intubations, epidural blood patches, critical care, and acute pain rounding, just to name a few. These clinical examples are all separately reportable to insurance for payment consideration, but only if your biller is made aware of their existence.
EMR Strategies to Capture All Billable Events
In an EMR setting, one way to ensure 100% reconciliation is to request a daily report from the hospital that shows every clinical service charted by one of your practice providers’ NPI numbers. You’ll be able to quickly check off the anesthetics already in the billing system and then focus on the one-off clinical services. A paper or digital charge ticket is another way to capture everything that a provider expects to be billed. Make sure to add check boxes for OOR items (just as you would for blocks and lines), so that coders know to look for the supporting source documents.
Of all anesthesia services, acute pain rounds are the easiest to overlook and represent the highest volume. Since pain rounds are not billable until post-op day one (the day after surgery), they’re not likely to be charted on an anesthesia record, which would have been completed the day before. Rounds are documented using pain progress notes, which can be mapped to a biller upon request of a facility EMR. However, that’s not a fool proof system. As we know, technology “hiccups” can prevent a day’s batch from transferring to a biller, with no schedule to reconcile from. For this reason, we recommend that billing vendors create SOPs to identify the type of anesthetics or blocks that typically require pain rounding. For example, if your practice’s clinical policy is to round on all indwelling epidural catheter patients on POD 1, the billing department can establish rules engine edits to identify cases where an epidural catheter was placed. From there, they can check the following calendar day for potential pain visits by anesthesia staff.
Another commonly overlooked area is TEE services, performed in conjunction with cardiac anesthesia. If the TEE service (probe placement, diagnostic interpretation and report, or both) is not captured on the anesthesia record, it’s likely not being billed. Make sure that your revenue cycle team understands who the TEE-credentialed MDs are within your practice, the type of cardiac cases where this service is commonly utilized, and how to access the TEE reports.
Start Strong: Billing Accuracy Begins at Onboarding
In conclusion, the billing start-up process for new practices or service locations is the perfect time to discuss clinical case and procedural reconciliation. The more your biller understands the type of clinical services you provide, the greater their accuracy will be on the reconciliation front. Without these discussions, a different conversation will take place down the road, in the form of missing charges.
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.
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