Anesthesia Coding, Its Difficulties and Challenges

Unlike most other physicians who receive fee-for-service based payment, anesthesiologists are paid according to the base unit (how complicated the procedure is and how much skill it requires), time unit (time taken to provide anesthesia) and modifiers (special conditions affect anesthesia). Hence, accurate anesthesiology medical billing is highly dependent on the documentation. Back-end billing software designed for other medical specialties would not be appropriate for the anesthesia practice. Besides that, anesthesia medical coding involves several challenges such as start/stop times, multiple lumen and invasive line placement rules, cancelled cases, monitored anesthesia care, and improper documentation of medical direction. Let’s take a detailed look at the various issues involved in coding for anesthesia.

Report Time

Anesthesia time starts when the anesthesia provider begins to prepare the patient for anesthesia induction (normally in the case of intravenous access) and stops when personal attendance is no longer needed for that patient (patient is safely under postoperative supervision). The time unit is generally considered to be 15 minutes. Incorrect anesthesia time will lead to lost revenue, audits and even penalties for fraud practices. Coders need to confirm that the reported time is not exceeding the average turnover time when there isn’t necessary documentation that explains why the physician spent that much time with the patient. When coding, it is essential to remain very cautious in the following instances.

• Relief Time – Though most anesthesiologists are aware of start/stop times, they are unsure of how to handle relief times. Relief time or split time basically occurs when a physician takes over a case for another physician in the group where two separate start/stop time lines should be reported on the anesthesia record and charge ticket. Wrong documentation of relief time can cause a compliance problem. The coder should verify the document for this case and bill it in the name of the physician who spent most time with the patient, or who started the case.

• Rounding Time – Rounding anesthesia time up or down should be done with great care as imprecision in recording the minutes is one of the major issues that lead to compliance problems. Physician groups often round the time to the nearest 5-minute increment or estimate it on the basis of past experience. However, the start/stop time is to be reported to the nearest minute for Medicare.

• Discontinuous Time – There may occur breaks in anesthesia care when the anesthesia practitioner is no longer in personal attendance with the patient (for example, surgeon is not available and anesthesiologist leaves after appointing a non-anesthesia personnel to observe the patient). In these cases, practitioners (CRNAs and anesthesiologists) should report only the total anesthesia time for the sum of the continuous block of anesthesia care. They must document the actual start/stop time and check the discontinuous time box whenever needed. Good documentation should include the blocks of time before and after the interruption (for instance, 9:45 anesthesia out time, anesthesiologist leaves the patient, 10:30 anesthesia in time). Documenting in this way makes it easy for the auditor to understand the continuous and discontinuous periods of anesthesia. It is also important to make sure that the total anesthesia time is obtained after adding up the blocks of continuous time.

• Time Spent in Post-anesthesia Care Unit (PACU) – The average time for the anesthesiologist to spend with a patient in PACU is seven minutes (as per Medicare). If there is a large percentage of PACU time more than seven minutes, the auditor may assume it as fraud unless the organization submits relevant documents to provide a strong reason for the extra time taken. When coding for anesthesia, it is necessary to take a thorough look at the documentation to discover this kind of anomaly.

Though the typical average time unit is 15 minutes, it may vary according to how the carriers define the ‘Time Unit’. Coders need to verify with insurers how they define the anesthesia time and how they prefer reporting it for accurate medical billing.

Multiple Lumens Placement

Anesthesiologists are not paid separate payment for placing multiple lumens unless they did a central venous pressure and a Swan-Ganz with two separate lines or two sticks. But, they are required to document the line placements and monitoring. Never bill the time for the placement of post-operative block or invasive lines before administration of the primary anesthetic for the relevant surgery. Such services should be billed as a flat rate fee. Alternatively, the time spent for the placement of post-operative block or invasive lines should not be subtracted after the administration.

Time for Invasive Line Placement

The coders should not include the time for the placement of blocks post surgery (invasive line or epidural catheter), and before anesthesia induction or after anesthesia emergence in the anesthesia time though sedation and monitoring are involved during the block placement. The time for the placement of blocks after the induction and before emergence should not be deducted from the reported anesthesia time. If the anesthesia practitioner administers sedation only for the block placement, it should not be included in the reported anesthesia time.

The coders should code arterial, central line, epidurals, regional blocks and more as separate procedures and billed separately without including them in the reported time. The pain management services should be coded in conjunction with an operative anesthesia service.

Cancelled Cases

If a case is cancelled before anesthesia induction, the accurate evaluation and management (E/M) code should be reported along with the reason for the cancellation (for example, due to equipment failure). If it is cancelled after induction, report the code along with the appropriate modifier and time. The modifiers that can be used are:

• -53 for discontinued procedure
• -73 for procedures discontinued before providing anesthesia
• -74 for procedures discontinued after anesthesia administration or after the procedure begins

Unless anesthesiologists document the cancelled cases well, enough information may not be available to select the correct E/M codes and modifiers.

It is also of utmost importance to know which insurers accept modifiers and those that do not. If the carriers are not accepting the modifiers, such cases can be billed using the correct anesthesia code with the full base units and total time documented on the record in which the reason for cancellation is documented clearly.

Monitored Anesthesia Care (MAC)

While billing for MAC, give more focus to medical necessity. If a patient loses consciousness at any time, it should be considered as general anesthesia, no longer MAC. As local coverage determination varies according to carriers and changes rapidly, documentation is critical to support diagnoses and ensure reimbursement in the case of MAC.

Documentation of Medical Direction

The physicians must medically direct qualified providers in two, three or four concurrent cases and perform the following seven steps to bill for medical direction and become eligible for reimbursement.

• Perform a pre-anesthetic examination and evaluation
• Set up an anesthesia plan
• Participate personally in most critical and demanding procedures in anesthesia plan such as induction and emergence
• Make sure that a qualified individual performs every procedure in the anesthesia plan that are not performed personally
• Supervise the course of the administration of anesthesia at frequent intervals
• Be physically present and available in case of immediate diagnosis and treatment of emergency cases
• Provide post-anesthesia care as specified

If any of these steps are not performed or a task which is not permitted in medical direction is performed, then it is medical supervision which will lower the payment. Hence, the physician should document all the details of medical direction correctly.

Coders would use the modifier QK to identify the physician’s medical direction of two three or four concurrent cases and CRNA service; and QY to identify physicians’ medical direction of one CRNA. If the Centers for Medicare and Medicaid Services (CMS) can’t find adequate documentation of medical direction during audits, anesthesia practices will have to pay back the difference in payments.

To sum up, when coding for anesthesia, it is vital to stop assuming anything and keep up with the policies and guidelines of carriers. Be aware of all evolving rules that apply to the states (dollar amounts are assigned for specific geographic areas or simply conversion factors) for correct anesthesiology medical coding.