Anesthesiology medical billing is not based on a fee-for-service payment like other medical specialties. Reimbursement for anesthesiologists depends on the base unit (how complicated the procedure was and how much skill it required), time unit (how much time was taken to provide anesthesia) and modifiers (any special conditions that affect anesthesia). Therefore, proper documentation is crucial for this specialty. Using a back-end billing software may be suitable for other medical specialties but it is not efficient for anesthesiology. The major challenges associated with anesthesia medical coding are:
- Report Time – Though most anesthesiologist know the start (when the anesthesia provider starts to prepare the patient for induction) and stop (personal attendance no longer needed) time for anesthesia, the relief time (two separate start/stop time reported when a physician hands over a case to another physician) sometimes adds confusion. Relief time should only be reported by the physician who had spent the most time with the patient, or who had initially started the case. This requires rounding the anesthesia time up or down. Physicians normally round the time to the nearest 5-minute increment however, Medicare requires the start/stop time to be reported to the nearest minute. The average time a physician can spend with a patient in the Post-anesthesia Care Unit (PACU) is seven minutes. If it is more than seven minutes at a large percentage, the auditor would deem it as a fraudulent practice unless there are evident documents supporting why the extra time taken. If any breaks occur during anesthesia care, the total anesthesia time should be reported as the sum of the continuous block of anesthesia care. Good documentation would include the blocks of time before and after the break.
- Multiple Lumens Placement – Even though there is no separate payment for placing multiple lumens, there is an exception if the anesthesiologist did a central venous pressure and a Swan-Ganz with two separate lines or two sticks and documented the line placements as well as monitoring. The time for the placement of post-operative block or invasive lines before administration of the primary anesthetic for the relevant surgery should not be billed. Services of this kind should be billed as a flat rate fee. Do not subtract the time for the placement of post-operative block or invasive lines after the administration.
- Time for Invasive Line Placement – The time for the placement of blocks post surgery (invasive line or epidural catheter) and before anesthesia induction or after anesthesia emergence should not be included in the anesthesia time, even if the block placement involves sedation and monitoring. Alternatively, the time spent for the placement of blocks after anesthesia induction or after anesthesia emergence should not be subtracted from the reported anesthesia time. If the sedation is administered only for the block placement, that time should not be included in the reported anesthesia time. Epidurals, central line, arterial, regional blocks etc. should be coded and billed as separate procedures. Do not include them in the reported anesthesia time. Pain management services should be reported in conjunction with an operative anesthesia service.
- Cancelled Cases – Cases cancelled before anesthesia induction should be reported with an accurate evaluation and management (E/M) code and proper reasoning (for instance, equipment not working). If a case is cancelled after induction, it should be reported with an appropriate modifier (-53 (discontinued procedure), -73 (discontinued before providing anesthesia), -74 (discontinued after anesthesia administration or after the procedure begins)) and time. Providers should check whether or not the insurers accept modifiers. If modifiers are not accepted then these, cases should be billed using the correct anesthesia code with full base units and total time reported. The reason for cancellation should be clearly documented as well.
- Monitored Anesthesia Care (MAC) – When billing for MAC, special attention must be given to evaluate medical necessity. If a patient were to lose consciousness at any time, it would fall under general anesthesia, not MAC. Documentation is very critical in this case as local coverage determinations vary depending on specific carriers.
- Medical Direction Documentation – If any of the seven steps for medical direction is not performed or a procedure which is not allowed under medical direction is performed, then it will be designated as medical supervision which will result in a lower reimbursement. The documentation should clearly specify what is done during medical direction. If inadequate medical direction documentation is found during Centers for Medicare and Medicaid Services (CMS) audits, the anesthesia practices will have to pay back the difference. The modifier QK (identify the physician’s medical direction of two three or four concurrent cases) and QY (identify physicians’ medical direction of one CRNA) should be also used appropriately.
In essence, it is imperative to clearly understand the policies and guidelines of carriers when coding and billing for Anesthesia services. It’s crucial to have in-depth knowledge about all evolving rules that apply to your specific locality to ensure accurate anesthesiology medical coding and billing.