Anesthesia Coding Alert

Documentation is such an important area of anesthesia coding that studying the ins and outs of it could easily fill an entire issue of Anesthesia and Pain Management Coding Alert. Last month we looked at three prime areas to focus on to ensure your providers' documentation is up to par start and stop times, adequate signatures, and complete patient diagnoses.

 Now we'll look at four more important checkpoints to home in on to make your documentation and coding as accurate as possible.

Checkpoint 1: Meet the Medical-Direction Criteria

 All anesthesia coding must include a performance modifier to indicate whether an anesthesiologist, a CRNA or a resident handled the case, and in what capacity. Choices from a physician perspective include -AA (Anesthesia services performed personally by anesthesiologist), -AD (Medical supervision by a physician: more than four concurrent anesthesia procedures), -QK (Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals), -QY (Medical direction of one certified registered nurse anesthetist [CRNA] by an anesthesiologist) and -GC (This service has been performed in part by a resident under the direction of a teaching physician).

 An anesthesiologist must meet several criteria (often referred to as the Seven Rules of Medical Direction) before he or she can bill a case as medically directed. Clear documentation ensures that the anesthesiologist:

  performed a pre-anesthesia examination and evaluation
  prescribed an anesthesia plan
  personally participated in the most demanding procedures of the anesthesia plan, including induction and emergence
  ensured that any procedure in the plan that he or she did not perform was performed by a qualified anesthetist
  monitored the course of anesthesia administration at intervals
  remained physically present and available for immediate diagnosis and treatment of emergencies
  provided the indicated postanesthesia care.

 "In my opinion, the most problematic of the 'seven rules' is 'personally participated in the most demanding portions, including induction and emergence,' " says Eileen Ledbetter, RHIT, CS, CPC, anesthesia and pain management coder at Lahey Clinic in Burlington, Mass. "Induction can be documented in the chart as a specific time. Emergence occurs over a span of time that may continue into the recovery room. Documenting personal participation during this span of time may be difficult."

 Ledbetter's group includes a time line on the patient record to simplify documentation. The anesthesiologist indicates his or her presence at key portions of the procedure along the time line. She also recommends including definitions of ambiguous terms such as "immediately available," "immediate area" and "emergency of short duration" in your compliance plans so providers can be consistent in their interpretations of the criteria.

 Once you have met all of the criteria, you must ensure that the physician was involved in a maximum of four concurrent cases before they can [...]