Anesthesia Coding Alert

The Health Care Financing Administrations (HCFA) rules for medical direction of nurse anesthetists are fairly clear on some points, but still confusing on others. Once a physician has met the seven criteria that are required before he or she can be considered a medically directing physician (see the article Frequently Asked Questions for Billing Medically Directed Cases, on page 6 in the November 1999 Anesthesia Coding Alert), questions arise about other duties that may be performed concurrently. But to avoid looking fraudulent, tread very carefully.

HCFA has sanctioned six types of duties that can be performed concurrently by a medically directing physician. These are:

1. addressing an emergency of short duration in the immediate area

2. administering an epidural or caudal anesthetic to a patient in labor

3. performing periodic, rather than continuous,
monitoring of an obstetrical patient

4. receiving patients entering the operating suite for the next surgery

5. checking and discharging patients in the PACU

6. coordinating scheduling matters

Anesthesia professionals occasionally refer to these as the six permissible sins of medical direction. And as with many guidelines set forth by HCFA, anesthesia practices and coders often have trouble interpreting the guidelines.

Are There Exceptions to the Exceptions?

HCFA agrees that the duties listed above are reasonable, consistent with sound medical practice, and would not cause the medically directing anesthesiologist to be in violation of HCFAs rules for medical direction, according to Cahaba GBA, Georgias Medicare carrier. At least thats the case as long as the medically directing anesthesiologist remains physically present and instantly available for immediate diagnosis and treatment of emergencies (one of the seven medical direction criteria).

But what about duties that are similar to the ones listed above, but not exactly the same? Are they considered permissible sins as well?

Thats a question some practices have been struggling with for quite some time. A common example is an anesthesiologist doing epidural blocks right in the operating room (OR) suite for pain management. It doesnt take as long to do that as to place a labor epiduralcode 00857 (neuraxial analgesia/anesthesia for labor ending in a cesarean delivery [includes any repeat subarachnoid needle placement and drug injection and/or any necessary replacement of an epidural catheter during labor]) or code 00955 (neuraxial analgesia/anesthesia for labor ending in a vaginal delivery [includes any repeat subarachnoid needle placement and drug injection and/or any necessary replacement of an epidural catheter during labor])but many anesthesia coders would like to know: Does it count as one of the acceptable activities during medical direction?

When in doubt, err on the side of caution, advises Marjorie Brown, CPC, CHCC, manager of physician service organization with Rehmann Robson, PC, a CPA and consulting firm that does anesthesia billing in Muskegon, Mich. They bill for three anesthesiology groups, including one with 18 physicians. Brown says the rules are ambiguous, and she has heard of groups that try to stretch the limits.

When I first start billing for a new company, physicians who may not be filing appropriately are usually more apt to follow the guidelines once theyve been made aware of them, says Brown. We play it safe and follow the concurrency guidelines to the T. We dont want to even remotely look fraudulent.

The Guidelines May Change

Sandra Wood, a senior regional policy specialist with HCFA in Georgia, says that Browns interpretation of the guidelines is exactly right. Staff at our central office in Baltimore are meeting with representatives of the industry to try to find common ground on the issue, she says. The guidelines may be expanded or changed at some point down the road, but that decision has yet to be made. Even if the group decides to modify the guidelines, thats only the first step. Then the extent of the changes would have to be consideredcan it just be updated in the carrier manual, or will new regulations or legislation need to go into effect?

In the meantime, she continues, we recommend that providers and local carriers interpret the guidelines exactly as they are stated. We realize it can be frustrating, but we want to go through the review process carefully to be sure were reaching the best conclusions for everyone involved.