Conform to Your Particular Anesthesia Documentation Rules

Conform to Your Particular Anesthesia Documentation Rules

Compliance requires you to take into account the unique reporting requirements for your practice or facility.

The documentation necessary to support anesthesia services may vary, based on the anesthesia practice’s unique characteristics. For example, the documentation requirements for an anesthesia practice using a “care team” approach — employing medical directing anesthesiologists, certified registered nurse anesthetists (CRNAs), and anesthesia assistants (AAs) — will differ from those for a practice where the anesthesiologists personally perform all procedures. The documentation requirements for teaching facilities are different still, and even more comprehensive.
Ensuring your physicians’ documentation meets requirements unique to the practice or facility starts with a review of the basic documentation requirements, but must then consider alternative examples.
Basic Documentation Requirements
The National Committee for Quality Assurance (NCQA) publishes 21 elements in its Guidelines for Medical Record Documentation, with six listed as core components; however, not all of the requirements pertain to anesthesia providers (who do not usually have a patient relationship beyond, and unrelated to, anesthesia services provided for surgical procedures). From this list, the basic documentation principals applicable to anesthesia services are:

  • Each page in the record contains the patient’s name or identification (ID) number;
  • All entries in the medical record contain the author’s ID, which may be a handwritten signature, unique electronic ID, or initials (Note: If anesthesia practices are still using paper records, a staff log is recommended for all signatures and initials); and
  • The record is legible to someone other than the writer.

The American Association of Nurse Anesthetists (AANA) publishes comprehensive documentation guidelines on its website. The American Society of Anesthesiologists (ASA) does not publish documentation guidelines, but it does offer the guidelines: Basic Standards for Pre-Anesthesia Care, Standards for Basic Anesthesia Monitoring, and Standards for Postanesthesia Care. Solo CRNA practices may choose to follow AANA guidelines; however, this article is based on ASA information.
Pre-anesthesia Care
In accordance with the ASA guidelines, “An anesthesiologist shall be responsible for determining the medical status of the patient and developing a plan of anesthesia care.” The Center for Medicare & Medicaid Services (CMS) requires that a medical directing anesthesiologist sign the pre-anesthesia documentation. All of the following guidelines pertain to pre-anesthesia care, except during documented medical emergencies:

  • Reviewing the available medical record;
  • Interviewing and performing a focused examination of the patient to:
    • Discuss medical history, including previous anesthetic experiences and medical therapy;
    • Assess those aspects of the patient’s physical condition that might affect decisions regarding perioperative risk and management;
    • Order and review pertinent available tests and consultations as necessary for the delivery of anesthesia care;
    • Order appropriate pre-operative medications;
    • Ensure that consent has been obtained for the anesthesia care; and
    • Documenting in the chart that the above has been performed.

Intra-operative Anesthesia Care
The ASA developed Standards for Basic Anesthesia Monitoring in 1986, which were last updated October 20, 2010. Although emergency circumstances and life-saving measures take precedence, the following broad standards apply, with defined methods:
Standard I – Qualified anesthesia personnel shall be present in the room throughout the conduct of all general and regional anesthetics and monitored anesthesia care (MAC).
Standard II – During all anesthetics, the patient’s oxygenation, ventilation, circulation, and temperature shall be continually evaluated.
Post-operative Anesthesia Care
Standards for Post Anesthesia Care were last updated October 15, 2014, by the ASA. They apply to general, regional, or MAC provided at any location. The standards require all patients, unless specifically ordered otherwise by the anesthesia provider, to be admitted to a post-anesthesia care unit (PACU) or equivalent area. The anesthesia provider is responsible for the patient, including support appropriate to the patient’s condition, until the patient’s care is transferred to a PACU nurse.
Reviewing Documentation
Anesthesia record auditors check anesthesia graphs, available on both paper and electronic records, to ensure continuous monitoring by the anesthesia provider, and to confirm the reported anesthesia time.
One method for doing this is to review both the documented time along the top of the anesthesia graph and count the “tick” or monitoring checks as a five-minute increment, based on ASA’s guidelines of monitoring and evaluating the patient’s arterial blood pressure and heart rate at least every five minutes. These monitoring checks should begin shortly after the reported anesthesia start time and end in proximity to the reported anesthesia stop time, unless documentation supports a delay or complication. Another method compares reported anesthesia times to the operating room circulator and PACU notes. Although these times rarely match exactly, they should be close to the reported anesthesia times. Time checks are the same for any type of anesthesia practice.
Documentation in the medical record should support reported anesthesia modifiers. Anesthesia modifiers have been listed on the Office of Inspector General (OIG) watch list since 2013. Medical direction modifiers (see the Anesthesia Modifiers sidebar) indicate to CMS and other insurers that certain steps have been followed by the medical directing anesthesiologist, as defined in the Medicare Claims Processing Manual, chapter 12, section 50, Payment for Anesthesiology Services. According to CMS, “Medical direction occurs if the physician medically directs qualified individuals in two, three, or four concurrent cases and the physician performs the following activities.” These are also known as the “seven steps” of medical direction:

  1. Performs a pre-anesthetic examination and evaluation;
  2. Prescribes the anesthesia plan;
  3. Personally participates in the most demanding procedures in the anesthesia plan, including induction and emergence;
  4. Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist;
  5. Monitors the course of anesthesia administration at frequent intervals;
  6. Remains physically present and available for immediate diagnosis and treatment of emergencies; and
  7. Provides indicated post-anesthesia care.

CMS allows six exceptions in the online manual that some carriers (such as Palmetto GBA) consider to be illustrative such as:
1. Addressing an emergency of short duration in the immediate area;
2. Administering an epidural or caudal anesthetic to ease labor pain;
3. Periodic, rather than continuous, monitoring of an obstetrical patient;
4. Receiving patients entering the operating suite for the next surgery;
5. Checking or discharging patients in the recovery room; and
6. Handling scheduling matters.
Frequently asked questions on Palmetto GBA’s website indicate:

As long as the medically directing anesthesiologist ‘remains physically present and available for immediate diagnosis and treatment of emergencies’ (rule number “vi” of the CMS “seven requirements”), we agree that the following procedures would be an illustrative but not exclusive list of allowed interventions:

  • Placement of a Swan-Ganz catheter, central line or arterial line
  • Placement of an epidural catheter for post-operative analgesia or in preparation for subsequent surgery (for a ‘to follow case’)
  • Placement of other peripheral nerve blocks prior to subsequent surgery, to include brachial plexus blocks, ankle blocks, femoral nerve blocks, etc.

Any anesthesia practice working with “qualified” individuals, including residents, fellows, CRNAs, AAs, and student registered nurse anesthetists (SRNAs), should be aware of CMS’ medical direction requirements and exceptions. Many private payer policies have also adopted these guidelines.
Teaching Physician Rules
Anesthesia practices involved in teaching have additional rules to follow. Information regarding teaching documentation requirements is available in the Medicare Claims Processing Manual, section 100, Teaching Physician Services. A teaching physician is defined as “a physician (other than another resident) who involves residents in the care of his or her patients.” Anesthesia services furnished in teaching settings are paid under the Physician Fee Schedule if the services are:

  • Personally furnished by a physician who is not a resident;
  • Furnished by a resident where a teaching physician was physically present during the critical or key portions of the service.

Electronic anesthesia records (EARs) are helping to improve teaching documentation because they clearly identify who was in the room, who provided which service, and include a legible attestation from the teaching anesthesiologist.
If more than one teaching anesthesiologist worked with a resident, Medicare requires the claim to be filed under the teaching anesthesiologist who started the case by appending modifier GC to indicate which services were performed by the resident. CMS does not require modifier GC for SRNA services because the modifier description pertains only to residents or fellows, depending on the circumstances.
Example 1: A teaching CRNA (not under the medical direction of an anesthesiologist) has two concurrent Medicare cases with SRNAs. The teaching CRNA documents presence and participation in the first case from 6:58 a.m. through 7:12 a.m., and in the second case from 7:13 a.m. to 7:21 a.m. The teaching CRNA must document the exact time spent in each of the two cases and ensure they do not overlap. The CRNA also must be present during both the pre- and post-anesthesia care. Report both cases to Medicare, with the full amount of time for each case, using modifier QZ. Documentation must support the CRNA involvement. Medicare will pay 100 percent of the approved amount for each case.
CMS allows a teaching CRNA to report full base and anesthesia time (modifier QZ) under the teaching CRNA’s provider number for two concurrent cases, provided the teaching CRNA is not medically directed by an anesthesiologist, and the CRNA is present with the SRNA during the pre- and post-anesthesia care for each case. The CRNA must document her or his involvement with each of the two cases.
Example 2: A teaching anesthesiologist is involved with two Medicare cases with SRNAs. The teaching physician documents presence and participation in the first case from 6:58 a.m. through 7:12 a.m. and the second case from 7:13 a.m. to 7:21 a.m. The teaching physician must continue documenting the exact time spent in each of the two cases, ensuring the times do not overlap. The teaching physician must be present during both the pre- and post-anesthesia care. Both cases are reported to Medicare with the full amount of time for each case with modifier QK (no modifier is reported for the SRNA services). Documentation must support the physician’s involvement. Medicare will pay 50 percent of the approved amount for each case.
Conversely, CMS allows a teaching anesthesiologist to report either personal performance (modifier AA) if she or he is continuously involved in a single case with an SRNA or the medical direction (modifier QK) for two concurrent cases, provided the steps for medical direction have been followed. In effect, a teaching CRNA may receive full payment for teaching two SRNAs; whereas, a teaching anesthesiologist only receives payment for his or her medical direction. No payment is made under Part B for services provided by an SRNA. This is important to keep in mind if an SRNA solely places an arterial line, for example, without the teaching CRNA’s or anesthesiologist’s documented involvement.
Review Records to Ensure Compliance
Your office can conduct internal reviews at any time. The person conducting the review should be someone other than the person who performed the work (for example, coding anesthesia charges). When internal reviews are conducted prior to reporting the services, any applicable corrections may be made. External audits may require attorney/client privilege. Your external auditor should be well versed in the nuances of anesthesia billing.
Depending on your compliance plan or policy, anesthesia practices conduct either internal or external reviews (or a combination of both) to spot-check documentation, as compared to the information sent to CMS or other insurance companies. There are additional areas of documentation concern — some general and some specific to anesthesia. The medical record should support all information provided on an anesthesia claim form, with examples indicated below:

  • Provider of medical service
  • Diagnosis and procedure codes
  • Anesthesia times, including documented discontinuous anesthesia time and any case relief or transfer of patient care. This is particularly important if your state Medicaid has a face-to-face policy for reporting labor epidural services.
  • General, regional, or MAC. CMS and other insurance companies may have medical necessity policy and/or require modifier QS, G8, or G9 when MAC is provided.
  • Indication of physician or teaching CRNA presence at induction, emergence, and other demanding procedures. Note: Induction and emergence are not applicable to MAC.
  • Procedure notes for invasive monitoring lines and/or other surgical procedures, including who provided the service and when. Time notations allow coders to determine when blocks or catheters are placed and whether discontinuous time is applicable.
  • Surgeon’s request for post-operative pain management, when applicable
  • Qualifying circumstances, such as an emergency*
  • Physical status, such as a patient with a severe systemic disease*

* Although CMS does not allow the reporting of physical status modifiers or qualifying circumstances procedure codes, other insurances may recognize and pay for these difficult anesthesia situations.
Documentation compliance is more than just an expectation — it’s a necessity. Regardless of whether your anesthesia practice has a formal compliance plan, per the Office of Inspector General’s Compliance Program Guidance for Third-Party Medical Billing Companies, all healthcare providers should be using internal controls to “more efficiently monitor adherence to applicable statutes, regulations and program requirements.” It’s vital for anesthesia service providers to understand what information is billed on their behalf and whether they conform to these readily-available guidelines.
Anesthesia Modifiers
AA Anesthesia services performed personally by the anesthesiologist
AD Medical supervision by a physician: more than 4 concurrent anesthesia procedures
G8 Monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive surgical procedure
G9 Monitored anesthesia care for patient who has a history of severe cardiopulmonary condition
QK Medical direction of 2, 3, or 4 concurrent anesthesia procedures involving qualified
QS Monitored anesthesia care service
QX CRNA service: with medical direction by a physician
QY Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist
QZ CRNA service: without medical direction by a physician
GC This service has been performed by a resident under the direction of a teaching physician
Modifier GC is reported by the teaching physician to indicate he or she rendered the service in compliance with the teaching physician requirements in section 100.1.2. One of the primary payment modifiers must be used with modifier GC.
AANA, “Documenting the Standard of Care: The Anesthesia Record:”
ASA, Standards & Guidelines:
CMS, Medicare Claims Processing Manual, Chapter 12 – Physicians/Non-Physician Practitioners:
NCQA, “Guidelines for Medical Record Documentation:”
OIG, 2015 Work Plan:
OIG, Compliance Program Guidance for Third-Party Medical Billing Companies, Federal Register, Vol. 63, No. 243, Dec. 18, 1998:
Palmetto GBA, Railroad Medicare, “Rules for Medical Direction of Anesthesia: Answers to Common Questions.”

Kelly D. Dennis, MBA, CPC, CPC-I, CANPC, ACS-AN, CHCA, has more than 32 years of experience in anesthesia coding and billing and speaks about anesthesia issues nationally. She has a master’s degree in Business Administration. Dennis serves as lead advisor for the anesthesia Board of Medical Specialty Coding and has owned her own consulting company, Perfect Office Solutions, Inc., since November 2001. She is a member of the Ocala, Fla., local chapter.

Anesthesia and Pain Management CANPC

No Responses to “Conform to Your Particular Anesthesia Documentation Rules”

  1. Michael McCartney says:

    Great summary of the requirements. I’ve read many times that we need to perform and document the “seven steps” of medical direction. What’s the best way (and the most common ways) for an anesthesiologist to document that they “provided the indicated post-operative care”? Is our signature on the Post-Anesthesia Evaluation note sufficient? If patients are discharged by physician order, is that sufficient? I can’t find anything in the CMS Conditions of Participation or elsewhere that clarifies the issue.

  2. Kelly Dennis says:

    Sorry for the delayed response! I just found this query while searching for information on the AAPC website! I will share the documentation requirements I look for when reviewing accounts. Although they are no longer available on the internet, these were published by CIGNA several years ago as follows:
    All States, GR 00-2, March/April, Inside This Issue
    Documentation Guidelines for Medical Direction by an Anesthesiologist Based on HCFA Final Rule on TEFRA 11/2/98
    The Final Rule on the Tax Equity and Financial Responsibility Act (TEFRA) published by the Centers for Medicare & Medicaid Services (HCFA) on November 2, 1998, included seven requirements for medical direction of anesthesia cases. The additional information that follows each requirement listed below is the documentation expected by CIGNA Government Services (CIGNA Government Services). CIGNA Government Services will use the documentation guidelines when reviewing records for medical direction by an anesthesiologist. Append the modifier -QK (medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals) to an anesthesia service HCPCS code to report medical direction by an anesthesiologist.
    HCFA’s seven requirements for medical direction are:
    1. “Performs a pre-anesthetic examination and evaluation.”
    The physician should evaluate the patient, performing an appropriate history and physical examination to adequately plan the anesthetic. This must be specifically documented in the medical record.
    2. “Prescribes the anesthesia plan.”
    The physician should personally prescribe and document the anesthesia plan.
    3. “Personally participates in the most demanding aspects of the anesthesia plan, including, if applicable, induction and emergence.”
    During anesthetics that are not considered to be general, (i.e., regional and/or MAC anesthetic), there is no period of induction or emergence. During general anesthetics the physician should document his or her presence and availability by appropriate signing of the anesthetic record, to indicate in a chronological fashion, participation in induction and emergence. Monitoring of the patient during emergence can occur at any time in the process of emergence.
    4. “Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified individual.”
    Although no specific documentation in each patient’s record is required, records of current licensure and training certification should be maintained. Knowledge of the individual’s skill set and training is recommended.
    5. “Monitors the course of anesthesia administration at frequent intervals.”
    For a general anesthetic lasting one hour or less, the documentation of presence during induction and at some point during emergence will be sufficient. If the anesthetic lasts longer than an hour, at least one visit to the operating room should be documented.
    6. “Remains physically present and available for immediate diagnosis and treatment of emergencies.”
    No specific documentation is required.
    7. “Provides indicated post-anesthesia care.”
    Standing orders in the Post-anesthesia Care Unit (PACU) are sufficient but should be dated and signed appropriately.
    A legible identification of the directing anesthesiologist is required on each page of the record. Change of medical direction should be documented.

  3. Laurene Paul says:

    I am wondering if the anesthesiologist, when in a teaching situation, has appropriatly documented they were present for the “key portions” of the procedure and an arterial line is placed, do they need an additional note to indicate they were present for the entire procedure since the A-line is a minor procedure? Or would the “key portions” apply to any other procedures performed? They are indicating that the line placements are a key portion of the anesthesia. Thanks

  4. Kelly Dennis says:

    Again, I found this question while searching the web for information! I marked notify me of any future comments, but didn’t receive this query. In my opinion, the arterial line can be considered a key portion, although the procedure note should clearly identify who placed the line. As the resident placed under the direction of teaching physician, a GC modifier would be added to 36620.