Anesthesia Start/Stop Time: Accuracy Counts

The key to avoiding compliance problems is watching the clock.

By Cody P. Jones, CPA, MBA, ChFC
Among the major medical specialties, anesthesiology has long represented a relatively small percentage of total health care costs and generally has not been the target of aggressive payer scrutiny or audits.
That will likely change as the government’s new Medicare audit initiatives gain traction. Chief among these programs is the Recovery Audit Contractor (RAC) program, a nationwide effort relying on independent contractors to ferret out improper provider payments in exchange for a percentage of the dollars recovered.
Because of the incentivized nature of the RAC program, reimbursement investigations are expected to be pursued in numbers and with a tenacity not previously witnessed in the Medicare arena. As a result, anesthesiologists should take steps today to ensure that billing policies comply with both public and commercial reimbursement guidelines.
One area that bears particular attention is the recording and subsequent billing of anesthesia start and stop times. Too often, anesthesiologists and certified registered nurse anesthetists (CRNAs) lack a clear understanding of when anesthesia time starts and ends. The result can be overbilling, which leaves the group vulnerable to compliance action, or underbilling, which costs the practice money.
In any case, ensuring that practitioners understand what constitutes anesthesia time is important both for reducing compliance risk and strengthening collections.

Define Time by Personal Attendance

The Centers for Medicare & Medicaid Services (CMS) defines surgical anesthesia time as the continuous, actual presence of the anesthesiologist or CRNA. Surgical anesthesia time begins when the physician or CRNA starts preparing the patient for the anesthesia procedure—in the operating room or equivalent area—and ends when the anesthesia practitioner is no longer in personal attendance.
The CPT^® definition is similar: “Anesthesia time begins when the anesthesiologist begins to prepare the patient for the induction of anesthesia in the operating room or in an equivalent area and ends when the anesthesiologist is no longer in personal attendance, that is, when the patient may be safely placed under postoperative supervision.”
In both definitions, time is counted from the moment the practitioner—having completed the preoperative evaluation—starts an intravenous line, places monitors, administers pre-anesthesia sedation or otherwise physically begins to prepare the patient for anesthesia. Time continues through the case and the period during which the practitioner accompanies the patient to the post-anesthesia recovery unit (PACU). Time stops when the practitioner releases the patient to the care of the PACU personnel.
Note: The time spent reviewing the patient’s medical record prior to surgery is not billable anesthesia time. This is considered part of the pre-operative evaluation which is compensated through the procedure’s base units.
Acute post-op pain services and invasive monitoring lines used in conjunction with anesthesia also factor into the reporting of total anesthesia time. The treatment of the time required to perform these services is contingent upon when they are performed during the patient’s surgical care.
When provided before anesthesia time starts (pre-operatively) or after it ends (post-operatively), the time spent performing these services should not be included in anesthesia time. This is true for pain blocks, regardless of the sedation level and monitoring provided to the patient for the block. Conversely, when the block is provided intra-operatively, the time spent placing the line or performing the post-op pain service is not subtracted from total anesthesia time.

Account for Discontinuous Time

CMS and most insurers recognize there may be breaks or interruptions in anesthesia care where the anesthesia practitioner is no longer in personal attendance with the patient. When this occurs, the practitioner is allowed to include the blocks of time before and after the interruption, as long as the practitioner is furnishing continuous anesthesia care within the time periods reported.
Here are several examples of the appropriate use of discontinuous time:

• The anesthesiologist has begun preparing the patient for induction, but the surgeon is temporarily unavailable and the anesthesiologist leaves the patient under the observation of non-anesthesia personnel.
• An intravenous (IV) is started in the induction room, but there may be a break before induction of anesthesia in the operating room. As long as there is continuous monitoring of the patient within the blocks of anesthesia time, those blocks may be aggregated.

Discontinuous time should be accounted for with precision. For example:

• 7:55 a.m.: CRNA starts an IV and places monitors in pre-op.
• 8:02 a.m.: CRNA leaves patient in pre-op with OR personnel (start of discontinuous time).
• 8:26 a.m.: CRNA returns and takes patient to operating room; case ends at 9:56 a.m.
• 10:02 a.m.: Patient is released to PACU personnel.

In this case, anesthesia time equals 103 minutes (127 total minutes minus 24 minutes of discontinuous time).
Fortunately, most practice management and documentation software applications allow for the entry of multiple anesthesia start and stop times to accommodate discontinuous time.

Relief Time Requires Two Lines

Relief time or split time occurs when one physician takes over a case for another physician in the group. In these instances, two separate start/stop time lines should be documented on the anesthesia record and charge ticket. Bill the case either under the name of the physician who spent the most time with the patient or under the name of the physician who started the case.

Watch for Improper Rounding

One area involving anesthesia time that frequently can lead to problems is imprecision in recording the minutes involved. Because Medicare recognizes 15 minute time units and pays to the tenth of a unit (1.5 minutes), physicians should report exact minutes for both start and stop times. Too often, groups round to the nearest five-minute increment, or worse, estimate the time involved based on past experience. A good indication of potentially inappropriate rounding is if more than 20 percent of a practice’s start and stop times are fixed on five-minute intervals.

Provide Necessary Additional Information

To ensure compliant claims and appropriate reimbursement, additional documentation should be included in certain circumstances or situations. As a general rule, if more than 15 minutes pass from the anesthesia start time to the time the patient is taken into the operating room, the delay should be explained in the anesthesiologist’s notes.
Similarly, if more than 15 minutes elapse between the operating room (OR) time and the start of surgery, an explanation should be provided. The industry standard for the amount of time between transferring the patient to the recovery room and the anesthesia stop time is five to 15 minutes. If it is longer than this, the documentation should clearly explain the reasons for the prolonged anesthesia time.

Precision is Key

As government and commercial payers become more aggressive in pursuit of improper provider reimbursements, more anesthesiology groups can expect to face audits and investigations of clinical documentation, coding, and claims procedures. Start/stop times represent one area of major vulnerability for anesthesia groups. As a result, it behooves practices to revisit their start/stop time procedures to ensure rigorous compliance policies are firmly established and in place—before the auditors arrive.

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