Anesthesia Coding Alert

Documentation is the anesthesia providers best friend its the key to reimbursement. But if your documentation of time, patient diagnoses, and physician signatures isnt up to snuff, it could be your worst enemy. Be Consistent With Start and Stop Times Much of anesthesia reimbursement is based on time units, so accurately documenting the time the anesthesiologist spends with patients is imperative.
 
We dont begin counting time when we first see the patient because at that point were conducting the pre-op evaluation thats part of the procedures base units, says Tammy Reed, billing manager for the anesthesia depart-ment of Oklahoma University Health Science Center in Oklahoma City. Instead, Reeds department uses the time that they begin preparing the patient for induction as the procedure start time. Sometimes we induce just prior to taking the patient to the OR, but some patients are already in the OR when the anesthesiologist induces them.

 In our group, anesthesia start time begins when the provider starts preparing the patient for induction and is in personal, continuous presence with the patient, says Eileen Ledbetter, RHIT, CS, CPC, anesthesia and pain management coder at Lahey Clinic in Burlington, Mass. We go this route because its in compliance with Medicare regulations and ASA guidelines.
 
Consistency is the biggest problem many coders face with documenting start and stop times. We try to stress using their own personal watches and not the OR clocks when theyre noting times, Reed says. The clocks in various OR rooms arent always synchronized, which means a provider can have overlapping times if he or she goes from one room to another. Unsynchronized clocks can affect concurrency issues and change whether an anesthesiologist is meeting the criteria for medical direction versus supervision (the physician can medically direct two, three or four concurrent cases; case loads that surpass four must be coded as medical supervision, a classification that comes with a pay cut).
 
You should also have clear documentation of when cases are passed from one member of the anesthesia team to another. For example, Dr. Jones may begin a case at 8:03. Dr. Brown takes over the case at 12:30 and finishes it at 16:35. Dr. Jones note reads, 12:30, case reviewed with Dr. Brown, and patient care turned over to Dr. Brown. Dr. Browns note reads, 12:30 case reviewed with Dr. Jones, and received patient case from Dr. Jones. Case ended at 16:35. The physicians write and sign these notes in the records comment area.

 We can usually tell by the writing when the change-over took place, but it still needs to be officially documented, Reed says.

 Reed recommends setting a policy of using military times for all cases (as in the example above). A concrete policy prevents having some [...]