Anomalous Anesthesia Billing Practices – Review of A JAMA Study

by | Last updated May 15, 2023 | Published on Dec 10, 2018 | Healthcare News

Anomalous Anesthesia Billing Practices Review of A JAMA Study
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AHIMA describes anesthesia as the administration of a drug or gas to induce partial or complete loss of consciousness. Anesthesia service provided by anesthesiologists, nurse anesthetists, or anesthesiologist assistants is reimbursable. These practitioners are paid in large part by the self-reported amount of time that they spend on a given case. Anesthesiology medical billing involves reporting length of time (anesthesia time) spent on each case, for reimbursement.

In the United States, the amount that insurers pay for a given anesthetic case is based on the number of anesthesia units it generates. Insurer regulations typically dictate that anesthesia time starts when the anesthesia practitioner begins preparing the patient for the procedure and ends when the patient is transferred to post-anesthesia care. Also, insurers require that practitioners report exact times without any rounding as they pay to the actual minute. A recently published study in JAMA Network Open helps to better understand the extent that anesthesia physicians may inappropriately choose billing details that affect payment for their services. This study found that anesthesia practitioners with a tendency to report times ending in a multiple of 5 minutes are more likely to submit billing times that correspond to higher payments for anesthesia services. This reflects anomalous billing.

In its April 2018 blog, AAPC had reported that Medicare requires exact time reporting from anesthesia practitioners, without rounding. An example given is that if anesthesia starts at 12:02 and ends at 12:59, the anesthesia time reported is 57 minutes. Medicare divides the 57 minutes by 15 minute increments, for a value of 3.8 time units. However, other insurance companies may determine time units differently. Regardless of the payer, coders should not expect to see documentation with large or unexplained gaps of anesthesia time, or times that always end with a “0” or “5.”

In this cross-sectional study of data from a large anesthesia registry, 6, 261,955 procedures performed by 4221 anesthesia practitioners (physician anesthesiologists, nurse anesthetists, and anesthesiologist assistants) between January 1, 2010, and March 31, 2015, were studied.

JAMA Network reports that this study suggests identifying inappropriate discretion through a 2-step process –

  • first, by using the presence of anomalous billing patterns with no clinical basis, such as an excess number of cases with an anesthesia time ending in a multiple of 5 minutes, to identify practitioners who may be billing anomalously
  • second, by estimating whether these practitioners report longer-than-expected anesthesia times based on observable clinical and institutional characteristics

It was found that practitioners with a tendency to round their times also reported anesthesia times 22 minutes longer than expected, corresponding to increased revenue ranging from $34 to $98 per case based on reimbursements by various payers.

The study also suggests potential cost savings from reducing the amount of discretion that healthcare practitioners have in determining the payment that they receive for a given service. When it comes to anesthesia, researchers suggest removing the time element and paying practitioners based solely on the type of case performed as a better alternative to the current payment policy, with which anesthesiologists would no longer be paid based on the self-reported amount of time spent on the case. Another potential policy recommended in this study is to explicitly tie the start and stop of anesthesia time to surgical times, such as the times when the patient enters and exits the operating room, typically recorded by a third party (the operating room staff).

Based on their findings, researchers also suggest that future studies should examine the degree to which physicians and other healthcare practitioners inappropriately use their discretion in determining reimbursement, as well as the potential effect of alternative payment policies. Documenting relief time and discontinuous time is also important. While relief time occurs when one anesthesia provider takes over the current case from another anesthesia provider, discontinuous time refers to breaks in anesthesia care in which the provider leaves the patient for any reason. Challenges with anesthesiology billing and coding can be minimized to a great extent with the support of a professional medical billing company, which helps anesthesia practitioners focus on providing their services peacefully.

In our next blog, we will discuss some common challenges with anesthesia billing and ways to resolve them.

Julie Clements

Julie Clements, OSI’s Vice President of Operations, brings a diverse background in healthcare staffing and a robust six-year tenure as the Director of Sales and Marketing at a prestigious 4-star resort.

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