Anesthesia billing and coding involves unique challenges and potential for error, which can lead to delayed payments, denials, and payer scrutiny or audits. Many providers outsource their billing to an experienced anesthesiology medical billing company to navigate these challenges and maintain the financial health of their practice. Calculating time units for anesthesia is an area that needs special attention to avoid overbilling and underbilling problems. In 2019, the Relative Value Guide (RVG) updates include revisions to the RVG definition of anesthesia time and field avoidance.

 Understand the RVG Definition of Anesthesia Time

 For correct coding and billing, practitioners need to understand what constitutes anesthesia time and record anesthesia start and stop times correctly. In a recent article, the American Society of Anesthesiologists (ASA) explains that the RVG definition of time in 2019 includes the concept of discontinuous time, which was not specifically addressed in the previous definition:

In the 2018 RVG definition, anesthesia time begins when the anesthesiologist begins to prepare the patient for anesthesia care in the operating room or in an equivalent area, and ends when the anesthesiologist is no longer in personal attendance, that is, when the patient is safely placed under post-anesthesia supervision.

The 2019 RVG update defines anesthesia time as the period during which an anesthesiologist is present with the patient.  It starts when the anesthesia practitioner begins to prepare the patient for anesthesia services in the operating room or an equivalent area and ends when the anesthesia practitioner is no longer furnishing anesthesia services to the patient, that is, when the patient is safely placed under postoperative care.  Anesthesia time is a continuous time period from the start of anesthesia to the end of a service.  In counting anesthesia time for services furnished, the anesthesiologist can add blocks of time around an interruption in anesthesia time as long as the practitioner is furnishing continuous anesthesia care within the time periods around the interruption.

Implications of the 2019 RVG Definition of Anesthesia Time

 The Centers for Medicare and Medicaid (CMS) and most private insurers accept that anesthesia care may involve breaks or interruptions, where the anesthesiologist is no longer in personal attendance with the patient. In such circumstances, the practitioner is permitted to include the blocks of time before and after the interruption, as long as the practitioner is providing continuous care within the reported time periods.

Important points to note:

  • Unlike the previous RVG definition, the 2019 definition of anesthesia time explicitly addresses the concept of discontinuous time. While it does not change how time is already being calculated, the ASA notes that the update is aimed at educating anesthesiologists and their practices on how to properly make use of this option and ensure compliance.
  • Discontinuous time should be precisely documented. According to the ASA, “discontinuous periods occur when there is an interruption in anesthesia services and the anesthesiologist is temporarily not in attendance for direct monitoring and care of the patient, despite not having completed the surgical procedure”.

An AAPC article provides the following examples of the proper use of discontinuous time:

  • The anesthesiologist starts preparing the patient for induction, but the surgeon is temporarily unavailable and the anesthesiologist leaves the patient under the observation of non-anesthesia personnel.
  • An intravenous (IV) is started in the induction room, but there may be a break before induction of anesthesia in the operating room. As the patient is continuously monitored within the blocks of anesthesia time, these blocks can be aggregated.

CMS billing rules recognize bundling of discontinuous time, either before or after the interruption as long as the practitioner is furnishing continuous anesthesia care within the time periods reported. The interrupted time between the continuous anesthesia time should not be billed.

  • Discontinuous time should not be used while the surgical procedure is in progress. Standard I in the ASA Standards for Basic Anesthetic Monitoring states that “Qualified anesthesia personnel shall be present in the room throughout the conduct of all general anesthetics, regional anesthetics and monitored anesthesia care.”
  • The ASA points out that the updated RVG definition is consistent with the CMS definition for anesthesia time from the Medicare Claims Processing Manual, Chapter 12, Section 50G (11/28/2018). However, there is one difference: while the RVG text states that time ends when the patient “is safely placed” under postoperative care, the CMS text states that time ends when the patient “may be placed safely” under postoperative care. This distinction between “is safely placed” and “may be placed safely” first appeared in the 2007 edition of the RVG to address Post-anesthesia Care Unit (PACU) back-ups when the patient could be safely transferred, but the anesthesiologist had to stay with the patient and provide postoperative care because the PACU could not accept the patient.

 Avoid Over-reporting / Under-reporting of Anesthesia Time

 Practices must be very careful to avoid over-reporting or under-reporting of anesthesia time. According to a recent study published in JAMA Open Network, industry stakeholders are raising questions about whether there is anomalous billing in anesthesia care. Reporting of inaccurate times can occur when an anesthesia case seems to take more time to complete than it should. As healthcare costs rise, anesthesiologists need to pay proper attention to reporting time correctly and preventing fraud and poor medical practices.

Medical billing outsourcing companies that specialize in anesthesiology revenue cycle management can be useful partners in practices’ efforts to strengthen collections while ensuring that their documentation and billing policies comply with industry regulations.