Revenue Cycle Insider

Don’t try to add extra time at the beginning — or the end!

Anesthesia can involve a lot of complex coding, and myths can generate in complicated situations.

See if your anesthesia coding is based on truth or legend with these commonly believed myths.

Myth 1: Anesthesia start time (AST) cannot start until you roll through the doors of the operating room (OR).

Busted! Incorrectly recorded anesthesia time cost anesthesia practices legitimate billing time, according to Nicholas Volpe Jr., MD, MBA, lead author of a study conducted between 2021 and 2022 and shared at an American Society of Anesthesiologists (ASA) advanced meeting in 2023.

While anesthesia practices may choose to start time when the patient enters the OR, they may be cutting themselves short. In the press release “Incorrectly recorded anesthesia start times cost medical centers and anesthesia practices significant revenue,” Volpe pointed out that “seemingly minor inaccuracies of recorded AST can cost medical centers and anesthesia practices hundreds of thousands of dollars in lost revenue.” While correctly identifying premedication and patient monitoring as billable anesthesia time, the article seemed to suggest that adding time to each case is acceptable … which leads us to the next myth.

Myth 2: It is OK to add a few minutes to the anesthesia start or end time to capture the extra time.

Busted!

It is never acceptable to add any extra time to the front end or back end of anesthesia time that is not documented with face-to-face time. To bust this myth, we’ll look to the ASA’s definition of time, last updated in 2019, which many payers follow: “Anesthesia time is defined as the period during which an anesthesia practitioner is present with the patient. It starts when the anesthesia practitioner begins to prepare the patient for anesthesia services in the operating room or an equivalent area and ends when the anesthesia practitioner is no longer furnishing anesthesia services to the patient, that is, when the patient is safely placed under postoperative care.”

It is clear the patient is not required to be in the OR to start anesthesia time, although the provider must be furnishing anesthesia services that are not related to the pre-anesthesia assessment, which is included in the base value. Which leads us to the next myth.

Myth 3: As long as you see the patient more than 48 hours before their surgery, you can bill a separate evaluation and management (E/M) service.

Busted! The ASA originally addressed this topic in November 2020 and revised the article in March 2023. The 48-hour timeframe comes from Title 42, Conditions of Participation (CoP) Code of Federal Regulations (CFR) §482.52(b)(1)], which says: “A preanesthesia evaluation completed and documented by an individual qualified to administer anesthesia, as specified in paragraph (a) of this section, performed within 48 hours prior to surgery or a procedure requiring anesthesia services.”

And we can’t stop there; next we look to the National Correct Coding Initiative’s (NCCI’s) NCCI 2025 Coding Policy Manual, Chapter 2, Anesthesia. According to the NCCI: “It is standard medical practice for an anesthesia practitioner to perform a patient examination and evaluation before surgery. This is considered part of the anesthesia service and is included in the base unit value of the anesthesia code.”

While there may be circumstances that will permit a separate E/M service, documentation must support the medical necessity of the separate visit, and the visit must be separate and distinct from the patient’s pre-anesthesia evaluation. The ASA provides vignettes to help determine when a separate E/M code may be warranted. Seeing all patients prior to surgery in a pre-anesthesia clinic to expedite the process on the day of surgery does not fall under medical necessity. Which leads us to the next myth.

Myth 4: Anesthesia is not normally required or is not medically necessary, so you cannot bill the service.

Busted, in multiple ways!

There may be times when anesthesia is not normally required, but due to extenuating circumstances, the patient does require anesthesia.

Modifiers and diagnosis codes help explain these special circumstances. For example, modifier 23 (Unusual Anesthesia) indicates the provider is administering general anesthesia for a procedure that does not normally require it. Medicare Administrative Contractor (MCA) WPS publishes a fact sheet explaining appropriate usage. As an informational modifier, this modifier will be reported after any applicable payment modifiers.

For example, a patient with Parkinson’s disease with dyskinesia and fluctuations has a therapeutic nerve block injection that is normally performed without anesthesia, and general anesthesia is administered by a personally performing physician with the patient in the prone position. The anesthesia crosswalk indicates that while “anesthesia care is not typically required, coverage/payment should not be denied when medically necessary.” Based on the pre-anesthesia assessment (which will be included in the base value), the anesthesiologist determined it was medically necessary to provide general anesthesia. The submitted claim form will include the correct anesthesia code and modifiers, such as 01992 (Anesthesia for diagnostic or therapeutic nerve blocks and injections (when block or injection is performed by a different physician or other qualified health care professional); prone position), AA, 23, and diagnosis code G20.B2 (Parkinson’s disease with dyskinesia, with fluctuations).

A second circumstance may be related to a patient requesting anesthesia for their convenience and comfort; the latest trend is anesthesia for tattoos. The ASA does not condone or support anesthesia at a strip mall tattoo shop or any setting without proper equipment or personnel to ensure patient safety. However, like any elective procedure, patients can choose to pay for these types of services in advance. Recommendations for anesthesia for tattoos was medically reviewed byAudra Webber, MD, ASA Committee on Ambulatory Surgical Care.

The final example is related to services the patient agrees to prior to their surgery, by signing an advanced beneficiary notice of noncoverage (ABN). Form CMS-R-131 (Exp. 01/31/2026) must be fully completed and signed before the patient has the service. In essence, the patient is acknowledging that they understand that Medicare may not pay for the service and they are willing to accept responsibility. There are modifiers for ABNs as well and, once again, we can look to WPS for an explanation about when to use modifiers GA (Waiver of Liability Statement Issued as Required by Payer Policy, Individual case), GX (Notice of liability issued, voluntary under payer policy), or GZ (Item or service expected to be denied as not reasonable and necessary).

Since the Medicare ABN form does not cover commercial payers, you can either create your own document of financial responsibility or adjust a template so it works for you.

Are there more myths? Of course! The bottom line is there will always be myths and there are resources to help you become a myth buster!

Kelly D. Dennis, MBA, ACS-AN, CANPC, CHCA, CPMA, CPC, CPC-I