Understand Payer Guidelines to Keep Up-to-date with Anesthesia
Both new and seasoned coders should know the many risk areas in anesthesia coding
By Kelly Dennis, MBA, CPC, CPC-I, CANPC, CHCA, ACS-AN
The American Medical Association’s (AMA’s) 2011 CPT® codebook was released without anesthesia-related code changes for this coming year. Because there are no changes to consider, it’s a good time to review both anesthesia coding basics and frequent coding problem areas.
Anesthesia services represent a small portion of CPT®, but correct anesthesia coding requires complete comprehension of various anesthesia guidelines. Services reported by anesthesia providers are not limited to anesthesia codes 00100-01999; and instructions found in the CPT® Anesthesia Guidelines do not cover many of the coding nuances specific to anesthesia billing (for instance, coding for the services of a certified registered nurse anesthetist (CRNA) or anesthesia assistant (AA)). Additional coding resources are required to gain a better understanding of anesthesia coding.
CMS and NCCI Offer Anesthesia Resources
The Centers for Medicare & Medicaid Services (CMS) and the National Correct Coding Initiative (NCCI) each publish information regarding anesthesia coding regulations. Although not all insurance companies follow CMS and/or NCCI guidelines, many use interpretations of both guidelines. Both publications are available through the Anesthesiologist Center of the CMS website.
The CMS Internet-Only Manual (IOM) (www.cms.gov/manuals/downloads/clm104c12.pdf, chapter 12) provides guidelines for both anesthesiologists (Section 50 – Payment for Anesthesiology Services) and CRNAs (Section 140 – CRNA Services). Although AAs aren’t mentioned specifically in the chapter heading under CRNA, the guidelines were revised in 2002 to include these providers. CMS recognizes both CRNAs and AAs as nonphysician anesthesia providers. Commercial insurances typically do not make a distinction between the two anesthetist types with regard to payment for services provided under medical direction of an anesthesiologist.
Although many practices are familiar with a care team approach that includes anesthesiologists and CRNAs, fewer may be familiar with AAs. AAs are licensed in 18 states and also are recognized under the TRICARE system. One important distinction between CRNAs and AAs (depending on state scope of practice, delineation of privileges by the facility, and individual malpractice carrier requirements), is that CRNAs may be allowed to practice as nonmedically directed, whereas an AA must be medically directed. See American Academy of Anesthesiologists Assistants, Facts about AAs (www.anesthetist.org/factsaboutaas/) for more information.
The most up-to-date version of the NCCI (as of this writing) is 16.3, which became effective Oct. 21, 2010. Anesthesia guidelines are found in chapter two. These guidelines for anesthesia coding are much more in-depth than CPT® guidelines and include an introduction to correct coding for anesthesia and information regarding which services are bundled. For example, time spent during the usual pre- and post-operative visits, patient monitoring, and various other activities are bundled into the base value of anesthesia services.
NCCI also discusses which services are billable separately. Separate procedure services, such as insertion of an arterial line (36620 Arterial catheterization or cannulation for sampling, monitoring or transfusion (separate procedure); percutaneous), Swan-Ganz catheter (93503 Insertion and placement of flow directed catheter (eg, Swan-Ganz) for monitoring purposes), and a central venous pressure line (36555 Insertion of non-tunneled centrally inserted central venous catheter; younger than 5 years of age and 36556 Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older) are payable separately to anesthesiologists, as well as to CRNAs/AAs if these procedures are furnished within the parameters of state licensing laws. The NCCI also provides examples of coding scenarios regarding postoperative pain management, ventilation management, and discontinuous time. The postoperative pain management example explains factors to help coders determine when postop pain is considered outside of the global surgical package.
Armed with the knowledge gleaned from these published anesthesia resources, you can gain valuable insight into information available to insurance companies. Keep in mind, however, that it is up to individual payers which guidelines to follow (for example, many payers follow guidelines set forth in the American Society of Anesthesiologists (ASA) Relative Value Guide® (RVG)).
Be Watchful of Payer-Specific Guidelines
Anesthesia coders should understand that anesthesia coding and billing guidelines will change from state to state and from payer to payer. Although CMS loosely follows the same IOM guidelines across all states, each state has its own idiosyncratic payer rules. This also is true for Medicaid, Blue Cross/Blue Shield (BCBS), and worker’s compensation. Individual payer contracts often include verbiage indicating their specific billing policies will be followed, yet they may not provide a copy of their coding/billing policy.
One of the best ways to ensure your practice is following individual state- and payer-specific anesthesia guidelines is to research which guidelines are available from your practice’s payers. The Internet has made it easy to access information; although, other sites may require provider login information (e.g., Blue Shield of California). If the information is not provided or accessible, it should be requested and reviewed on an annual basis, at a minimum. The onus for keeping up-to-date with changing regulations is placed solely on the anesthesia provider—who, in turn, typically relies on his or her coding and billing staff to know when changes occur.
Communicate Potential Risk Areas with Clinical Staff
Risk areas for anesthesia providers usually are understood by the coding and billing staff, but aren’t always relayed to the clinical staff. Coders understand the discipline, “If it wasn’t documented, it didn’t happen.” With anesthesia records, however, sometimes it is very difficult to determine the exact diagnosis and procedure code and/or who actually provided services.
For example, if the anesthesia record has a check box for placement of an arterial or central venous pressure (CVP) line, and both an anesthesiologist and CRNA or AA are involved in the case, a check mark doesn’t indicate clearly who placed the arterial line or CVP. Because many carriers require that services are filed under the name of the provider who performed the service, the service may go unbilled unless clear procedure notes are documented either in the Remarks or Comments section, or provided on a separate procedure form.
Another risk area is medical direction criteria. Many anesthesiologists fail to sign or initial their participation appropriately with a medically-directed case, and may consider their signature as sufficient documentation of involvement. CMS and other payers require documentation during the most demanding procedures in the anesthesia plan, which includes induction and emergence, when applicable. Unless a monitored anesthesia care (MAC) case converts to general, induction and emergence are not applicable. Similarly, there is not an induction or emergence period associated with regional anesthesia.
Time Really Can Be Relative
Time reporting on claims may vary, and there is no national guidance. According to the CPT® Anesthesia Guidelines, time units are reported as is “customary in the local area.” Although Medicare requires exact time reporting, other payers may request either rounded time, or time in units, rather than minutes. Anesthesia providers always should provide exact start and stop times on the anesthesia record which, according to the ASA, correlate with “when the anesthesiologist begins to prepare the patient for anesthesia care in the operating room or equivalent area, and ends when the anesthesiologist is no longer in personal attendance.” Coders should not expect to see large or unexplained gaps of anesthesia time around either the start or stop times, or times that routinely end with a “0” or “5.” Internal reviews of anesthesia times should be performed periodically.
Because there are many risk areas in anesthesia coding, it is our job as apprentice or certified coders to ensure we understand the importance of following payer guidelines and keeping up-to-date with changes. If you see risk areas in your practice, work closely with your anesthesia providers to ensure correct coding, documentation, and billing. Keep in mind that although there were no anesthesia code changes this year in the CPT® book, the RVG® may contain changes to either parenthetical notes or positions listed in the back of the guide. Make sure you check for verbiage or position statement changes when you receive your 2011 RVG®.
Kelly Dennis, MBA, CPC, CPC-I, CANPC, CHCA, ACS-AN, has over 27 years experience in anesthesia and speaks about anesthesia issues nationally. She serves as lead anesthesia advisor for Board of Medical Specialty Coding and has been consulting since November 2001.