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This is a continuation of our previous blog “Anomalous Anesthesia Billing Practices – Review of A JAMA Study

What makes anesthesia medical billing different from that for other specialties? Unlike physician payment which is based on a fee-for-service schedule, anesthesia providers are paid according to a different system consisting of base units, time units, and modifiers. Following certain intelligent billing practices can make a huge difference in your revenue.

Here are some common issues that anesthesia practitioners and billing and coding specialists at medical billing companies face when it comes to billing and reimbursement for anesthesia services.

Billing and Coding Errors

Manual errors in medical bills are a major reason for most claim reimbursement delays and denials. Different types of anesthesia have different billing codes, which can be confusing when assigning the medical codes. Having clear documentation on exactly which type of anesthesia is being used and making sure this carries through to the billing stage can help avoid such confusion.

Anesthesiologists perform various actions in the operating room and hence anesthesia billing comprises nearly all of the 13,000-plus procedure codes.

Assigning additional codes is significant, which can result in higher payment for the anesthesiologist or CRNA. Examples for such add-on codes are:

  • +99100 Anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure)
  • +99116 Anesthesia complicated by utilization of total body hypothermia (List separately in addition to code for primary anesthesia procedure)
  • +99135 Anesthesia complicated by utilization of controlled hypotension (List separately in addition to code for primary anesthesia procedure)

You need greater coding efficiency to get the complex anesthesia codes right. Absence of a knowledgeable and highly skilled workforce could result in greater revenue leakages.

As surgical services are being provided in a wider variety of settings, there is less control over the way procedures are monitored. Even one minor mistake in assigning codes can lead to an expensive, unmanageable bill.

Apart from coding mistakes, other common billing errors include waiting to confirm that the patient’s insurance will cover the procedure, incorrect recording of start and stop time,  including additional or ancillary services, not defining the services clearly as well as not having clear documentation on which type of anesthesia was used and carrying that information through to the billing stage. Insurance authorization services can reduce the chances for claim denials to a great extent by ensuring that the patient is covered for the service.

Report Time

Anesthesia reimbursement depends in part on the amount of time spent in providing care. Wrong billing time is the major cause of errors causing revenue loss. Reporting time can be confusing and/or complicated. Anesthesia time units are defined as the period during which an anesthesia practitioner is present with the patient. Most insurers, including Medicare require exact time reporting, without rounding. It’s important to make sure that the start and stop times are recorded and billed exactly as outlined in your contract. While Medicare calculates anesthesia at 15-minute intervals, it may differ for other payers.

Hospitals must make sure to have adequate monitoring in the operating room to record anesthesia time precisely.  It is recommended that CRNAs and anesthesiologists should only report the total anesthesia time for the sum of the continuous block of anesthesia.  Documenting discontinuous time is also essential. They must note down the actual start and stop time in the appropriate areas and also document discontinuous time in the remark section with legible notes. Make sure to set the standards with correct coding that gives a clear indication of the start and stop time with regard to the anesthesia process.

Coders should check whether the CRNA or anesthesiologist has documented the information so that an auditor can see the continuous and discontinuous periods of anesthesia.  Also, the records submitted must match the reported start and stop times. Remember to code arterial, central line, regional blocks, and epidurals as separate procedures, as these services are not included in the reported anesthesia time and are billed separately.

Recent reports highlighted anomalous billing patterns, where anesthesiologists were reporting high number of anesthesia times ending in a multiple of 5 minutes.

Use of Modifiers

Modifiers are added to the procedure codes while billing. Modifiers signifying physical status, age and emergency factors may be added to the procedure codes. The total number of units is then multiplied by a conversion value to create a total charge for the procedure. When billers are not fully aware of modifier usage, the result can be inappropriate billing and overpayments.

Medical coders should be aware of several modifiers and how to use them correctly to ensure proper claims payment.

Key modifiers, explained in an AAPC blog are:

  • A Anesthesia services performed personally by an anesthesiologist [or when an anesthetist assists a physician in the care of a single patient]
  • Y Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist
  • K Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals
  • D Medical supervision by a physician: more than four concurrent anesthesia procedures
  • X CRNA service: with medical direction by a physician
  • Z CRNA service: without medical direction by a physician
  • S Monitored anesthesia care service [to be billed only by a qualified non-physician anesthetist, anesthesiologist assistant, or physician]
  • 8 Monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive surgical procedure
  • 9 Monitored anesthesia care for patient who has history of severe cardio-pulmonary condition

When monitored anesthesia care (MAC) is provided rather than general anesthesia, it is crucial to alert the insurance company, as MAC is included in the payment for the procedure.

The best way to improve anesthesiology medical billing is by streamlining the process. Partnering with an experienced medical billing service provider can help practices take advantage of additional reimbursement opportunities.