Primary Mode of Anesthesia: Let’s Clarify!
The primary mode of anesthesia is one of the most mislabeled categories within an anesthesia record. This often leads to underbilling, unnecessary denials and delayed claims’ submission. This article is intended to help clarify the proper application of this important data element.
3 Main Types of Anesthesia
There are three main anesthesia types for billing: General, Regional and Monitored Anesthesia Care (MAC). It should be noted that with the exception of MAC, the anesthesia type is not required to be specified on a claim form and insurance payment is the same for all modes. However, there are nuances to this designation that need to be carefully considered by all anesthesia practices.
Types of Anesthesia Defined
Defined as a case in which the patient lost consciousness during some part of the procedure, regardless of duration. Airway access is not required. This means that the majority of Propofol/TIVA cases that you do qualify as a General Anesthetic.
Defined as a case in which the patient received an epidural, spinal, or nerve block as the primary anesthetic. The patient remains conscious throughout the entire procedure.
Monitored Anesthesia Care (MAC)
Defined as a case in which the patient received a sedative and/or anxiolytic (i.e., Versed) as the primary anesthetic. The patient remains conscious throughout the entire procedure.
Combined Anesthesia Techniques
Defined as a case in which two modes of anesthesia were used simultaneously, both as the primary anesthetic (General + Spinal).
Historical Problem Areas Concerning Designation
Planned Mode of Anesthesia Changes Intraoperatively
In some instances, the surgeon may schedule a case as a MAC, which is later performed under general anesthesia. Providers should check their records closely to ensure that the final anesthesia type is charted accurately.
Post-Op Pain Blocks
When a block’s primary intent is for post-operative analgesia, it should not be charted as being part of the primary anesthetic. Doing so will negate the ability to bill and be reimbursed for the block separately. Bottom line – The block can have a secondary adjunctive effect on the primary anesthetic, without being considered a combined anesthesia technique.
Incorrectly designating General Anesthetics as MACs
Insurance plans often scrutinize MAC anesthesia for payment purposes and require the claim to include a specific diagnosis code describing a patient’s underlying condition or an ASA Physical Status Modifier (3 or above) which substantiates medical necessity for the service. Billing companies are required to append a -QS modifier on MAC claims submitted to Medicare and other insurance plans, which alerts the respective payer that you are billing for a “conscious sedation” anesthetic.
Since surgeons can often provide their own conscious sedation for these procedures, the denial rate on such claims is far greater than those of General or Regional anesthetics. As noted above, pain blocks are also non-billable when this designation is used. For all of these reasons, it is imperative that the mode of anesthesia be carefully selected for each case. Doing so will help to improve the accuracy of your documentation and prevent unnecessary claims-related issues.
MSN Healthcare Solutions
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.