Anesthesia Coding Alert

Complete documentation for anesthesia relies on 10 basic must haves including correct use of modifiers, detailed reports, reasons for cancellation and start and stop times.

The more information the anesthesia record includes, the better, as far as insurance carriers are concerned. Robin Fuqua, CPIC, a certified insurance coder with Anesthesia Consultants of California in Escondino, and Pam Alexander, administrator of Northwest Arkansas Anesthesiologists in Jonesboro, Ark., recommend that anesthesia providers be trained (or reminded) to pay special attention to 10 areas when documenting their cases.

1. Physical status modifiers. All anesthesia services must include the procedure code as well as a physical status modifier describing the patients condition. The P1(a normal healthy patient) and P2 (a patient with mild systemic disease) modifiers are self-explanatory and do not require additional information. Documentation supporting a patients classification as P3 (a patient with severe systemic disease) or above must be evident before insurance carriers will reimburse at a higher level because of the risk factors involved with treating the patient. Fuqua says that the anesthesia records at some facilities allow the anesthesiologist to document the physical status and include space for the doctor to itemize what constitutes the patients status.

2. Details, details. Simply writing exploratory laparotomy or exp lap for resection, repairs or other similar procedures is not acceptable to many insurance carriers, and makes the coders job much more difficult. The more specific the anesthesia provider is about what takes place, the more accurately it can be coded and the more appropriate the resulting reimbursement will be. As Fuqua points out, patients rarely go into surgery without something specific being wrong with them.

3. Use those modifiers. The Health Care Financing Administration (HCFA) and the American Medical Association (AMA) have established many modifiers that provide more details about the services provided. Requirements for using modifiers may vary by carrier or by geographic area, so coders should always be sure to follow local guidelines. Modifiers follow the procedural code on the anesthesia record, and can describe circumstances such as a discontinued procedure (-53), repeat procedure by the same physician (-76) or distinct procedural service (-59). Most Medicare modifiers found in HCPCS describe who provided the service, such as -AA (anesthesia services performed personally by anesthesiologist) or -QZ (CRNA service: without medical direction by a physician). One of the newest modifiers some practices are now using is -QS to indicate monitored anesthesia care (MAC) service. Complete lists of modifiers with their definitions are in Appendix A of CPT 2000, and in the introduction of HCPCS 2000.

4. Pain management requests. Surgeons will often request that patients have some type of postoperative pain management care following a procedure. Alexander says the anesthesiologist may not need to document this separately since the surgeons orders for the service are in the patients medical record.

The physicians whom Fuqua codes for only need to list a general location of the pain when charging for pain management. For instance, she says that if a hysterectomy was performed (58150, total abdominal hysterectomy [corpus and cervix], with or without removal of tube[s], with or without removal of ovary[s]), 625.9 pelvic pain (pain and other symptoms associated with female genital organs; unspecified symptom associated with female genital organs) is listed as the diagnosis. If total knee replacement (27447, arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing [total knee replacement]) was done, 719.46 knee pain (other and unspecified disorders of joint; pain in joint; arthralgia) is the diagnosis. Follow-up codes used for pain management are CPT 01996 (daily management of epidural or subarachnoid drug administration) and ASA (American Society of Anesthesiologists) 01997 (daily hospital management of intravenous patient-controlled analgesia).

5. Medical necessity for MAC cases. We use the Medicare guidelines for the CPT and diagnosis codes, says Alexander. Fuqua is in a state where Medicare now requires documentation of MAC with the -QS modifier (monitored anesthesia care service) after each procedure (i.e., 66984-QS for an extracapsular cataract removal). She says that none of the facilities their practice uses has space on the anesthesia record to document MAC. Their staff is in the process of creating a new charge sheet that will allow the anesthesia team to mark when a case was handled with MAC.

6. Medical direction. Many anesthesiologists personally care for patients as well as oversee the care given by other members of their team. In order to bill a case as medically directed, the physician must meet several criteria, sometimes called the seven rules of medical direction, as mandated by HCFA:

1. perform a preanesthesia examination and evaluation
2. prescribe the anesthesia plan
3. personally participate in the most demanding aspects of the anesthesia plan, including, if applicable, induction and emergence of the patient
4. ensure that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist
5. monitor the course of anesthesia administration at intervals
6. remain physically present and available for immediate diagnosis and treatment of emergencies
7. provide indicated postanesthesia care

The anesthesia record Alexanders physicians use incorporates these criteria for meeting medical direction. She says the seven steps are each identified, and the medically directing physician signs off on the criteria with comments related to the case.

Another key component is accurately documenting hand-offs between anesthesiologists for medical direction of anesthetists, says Allen Holden, CPA, practice manager of Albany Anesthesia Associates in Albany, Ga. The record should show the start and end times for each anesthesiologists portion of the case, he explains. The charge entry person should enter these times in the billing software, and the concurrency verification must ensure that none of the physicians has inappropriate conflicts with other cases. Its important for your billing software to be able to account for time by multiple physicians during a case.

7. Line placement. The anesthesiologist should always document any line placements on the anesthesia record. The hospitals surgery record should also reflect that the physician is placing the line, such as an arterial, central venous or Swan-Ganz catheter.

8. Reasons for cancellation. Doctors need to tell us why surgery is cancelled once the patient has been anesthetized, or what cancelled surgery during the examination process beforehand, says Fuqua. She tells the story of a patient who was scheduled for a femoral-popliteal bypass graft (35656) and was in the operating room (OR) for more than an hour before the surgery was cancelled. The surgeon had been unable to find a usable vein to transplant in place of the damaged artery. Thus, the surgery technically had taken place since an incision had been made and the surgeon had explored looking for a good transplant candidate, but was cancelled because he came up empty.

Surgery usually is cancelled because of an unsatisfactory condition the patient develops just prior to the procedure (such as an asthmatic developing wheezing upon lying down, or a patient with heart palpitations that worsen to the extent that the patient is not stable enough to last through surgery). Alexander and Fuqua agree that any reason for cancellation should be clearly noted on the anesthesia record so the anesthesiologist can be reimbursed for whatever service was provided.

9. Start and stop times. Anesthesia time begins when the anesthesia professional sees the patient and begins doing the last-minute chart review, patient interview and authorizes the IV to be started. Anesthesia time ends after the patient is in the recovery room and is stabilized. Some physicians report the time the patient leaves the OR as the end to anesthesia time, but their time actually goes a little beyond that. The recovery room chart should note the time the patient is released to them; this is the actual end time for anesthesia care. Some coders say these little bits of time can add up, and even cross over into another time unit that is reimbursable, so its important to remind physicians about which ending time to document.

One of Medicares compliance guidelines is the seven minute rule. The general assumption is that anesthesia care should not be necessary for more than seven minutes after a patient has been released to the recovery room. The anesthesiologists must document why they may continue to charge for more than seven minutes after the patient has been moved to recovery, Fuqua says. She does acknowledge that they allow charges for more time in special circumstances. If the patient is discharged to ICU after heart or lung surgery of 13 base units or more, we cut them slack because of the severity of the surgery and the need to monitor the patient until anesthesia is out of their system and the patient is stabilized, she explains. We just need proper documentation of the situation before we try to send the claim through.

Holden also points out that the anesthesia start time on Medicare patients can be a little different than with other patients. If invasive lines are placed by the physician or anesthesia provider, Medicare says the anesthesia time should not include the time involved in placing lines that are separately billable as a surgical code, such as arterial lines and Swan-Ganz catheters. One example of this type of situation is with coronary bypass procedures. Medicare believes that anesthesia providers should not be paid for their time placing lines when a surgeon would receive only the procedure fee.

10. Patient charges. In addition to stressing complete and accurate documentation, some practices also are revising their records to include patient charges. Weve updated our groups anesthesia record to include all information necessary to charge patients for the service, Holden says. That way were eliminating a separate charge slip.

Know Whats Being Done

Before the anesthesiologist can accurately document the procedure he or she is assisting with, it has to be clear exactly what is being done. The anesthesiologist cannot assume that the planned procedure is what actually takes place because once the case begins, the surgeon may realize that the patient needs something different than anticipated. That means the anesthesia team must consult with the surgeon to make sure the anesthesia record reflects the correct procedure.

Procedures can change without much warning, says Fuqua. One example she cites is when an exploratory laparotomy (49000) becomes a more definitive procedure such as a splenectomy (38100).

Alexander says, The CRNA (certified registered nurse anesthetist) actually codes after the surgery, then the medically directing anesthesiologist reviews it. Of course, they know what type of procedure is planned beforehand, but by officially documenting it at the end theyre more apt to get it exactly right.

Different Facilities, Different Charts

Part of the trouble with thorough documentation is that every facility has its own anesthesia record with different sets of boxes, checklists or areas for remarks. No two forms are designed alike, and Fuqua says that unfortunately, none of the records at the facilities her group uses includes all the necessary items for complete documentation.

They all have good parts, but they all lack something essential, she says. Thats why their staff works together to design backup forms that help the providers include all the information needed for reimbursement. The bottom line is that these doctors are trained in medical school about charting, and overall they do it well, she says. Sometimes they just need to be reminded that the more thoroughly they can document their cases, the betterand more appropriatetheir reimbursement will be.