Anesthesia Coding Alert

There are three ways to bill for an anesthesiologists services: as personally performed, medically directed or medically supervised. Each requires a different modifier. The definitions in HCPCS Codes2000 are straightforward: modifier -AA (anesthesia services performed personally by anesthesiologist), modifier -AD (medical supervision by a physician, more than four concurrent anesthesia procedures), modifier -QK (medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals) and modifier -QY (medical direction of one certified registered nurse anesthetist). Coders need to work with the anesthesia providers to ensure that cases and especially the start and stop times associated with them are documented thoroughly to know which modifier to use to get the appropriate reimbursement.

Medical Direction

Cases that are performed personally generally are cut-and-dry in terms of coding simply report the appropriate procedure code along with modifier -AA. Some professionals seem to use the terms medical direction and medical supervision interchangeably, but they are definitely two distinct services that should be coded as such.

The Health Care Financing Administration (HCFA) has stipulated criteria (sometimes called the seven rules of medical direction) that the anesthesiologist must meet before a case can be considered medically directed. The physician should:

1. perform a pre-anesthesia examination and evaluation;
2. prescribe the anesthesia plan;
3. personally participate in the most demanding procedures of the anesthesia plan, including induction and emergence, if applicable;
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; and
7. provide indicated post-anesthesia care.

Once these criteria have been met whether the case is truly medically directed hinges on how many cases are concurrent and how accurately the cases are documented. If a medically directed case ends at 10:01 a.m. and another case begins at 10:01 a.m., can these cases be considered concurrent for medical direction purposes? Some states such as Alabama and Minnesota say yes; other states like Georgia say no. Coders must be familiar with the guidelines in their state and follow the carriers stipulations, says Carol Kolbinger, owner of the compliance consulting firm Anesthesia Compliance Solution in Rogers, Minn.

A busy anesthesia group in a busy hospital may have so many cases going on that its difficult to keep track of how many are concurrent, she says. Its crucial for the anesthesiologist to note accurately the start and stop times of each procedure he or she is involved in to tell which ones are concurrent. Many groups find that performing self-audits confirms that they dont exceed the 1:4 ratio for medical direction.

Medical directing involves four or fewer concurrent cases. The anesthesiologist continues to direct the cases until all are complete. Even if one case ends and another begins, the total amount the anesthesiologist can medically direct concurrently is four or fewer. If the total caseload passes four at any point, the cases are considered to be medically supervised.

A higher level of documentation is required for medically directed cases, Kolbinger adds. The physician must document in the medical record that he or she performed the pre-anesthetic exam and evaluation, provided indicated post-anesthesia care, was present during some portion of the anesthesia monitoring and present during the most demanding procedures. You get higher reimbursement for medically directed cases, but some practices opt for supervision situations to avoid the documentation requirements for medical direction.

Medical Supervision

The criteria for medical supervision, on the other hand, are slightly different. A physician is considered to be supervising an anesthetist when he or she:

1. performs other services for other patients that require continuing physician personal involvement or substantially diminish the scope of control exercised by the physician when directing the administration of anesthesia to the surgical patients;
2. is not physically present in the operating suite during the time of the anesthesia procedure;
3. does not provide services for medical direction;
4. is involved in furnishing more than four procedures
concurrently; and
5. ensures that a qualified individual is performing the services provided.

When the physician is involved in a decision-making capacity, certain services are considered to be part of the supervision. These include reviewing and verifying the pre-anesthesia evaluation performed by the other provider; reviewing the anesthesia plan; reviewing and commenting during the pre-anesthesia care (which may include a limited presence in the operating suite, although that is not required); and reviewing and commenting during the post-anesthesia care period.

A supervising physician does not have to be present during critical points in the procedure and available for immediate diagnosis and treatment of an emergency. He or she also may be performing anesthesia for another case or doing other work, and not be able to leave and be immediately available in the surgical suite (which is required for a case to be considered medically directed).

Reimbursement for Each

Opting for the supervisory situations over medical direction may make documentation easier, but it also impacts the providers bottom line. Medicares payment is based on a combination of base and time units for the procedure, multiplied by the appropriate Medicare anesthesia conversion factor. Payment for medical supervision is limited to three base units for the procedure multiplied by the anesthesia conversion factor: Charging for an additional time unit is allowed if the anesthesiologist is present at induction. Reimbursement for medical direction follows a formula of base units for the procedure plus the amount of time spent on the case.

The Alabama Blue Cross/Blue Shield manual gives the following formula for calculating charges for cases that are medically directed: (time units + base units) x conversion factor x 50 percent = Medicare-allowable charge. For example, an anesthesiologist provides care during bunion correction surgery (28296, correction, hallux valgus [bunion], with or without sesamoidectomy; with metatarsal osteotomy [e.g., Mitchell, Chevron, or concentric type procedures]). Procedures performed on the feet carry three base units. Assuming that the case takes place in a state with 15-minute time units and lasts for 30 minutes, reimbursement would be calculated as:

(2 time units + 3 base units) x the areas anesthesia
conversion factor x 50 percent (if the case is medically directed)
3 base units x the areas anesthesia conversion factor
(if the case is medically supervised)

Tips for Ensuring the Correct Type Is Billed

The appropriate performance modifier is billed with the procedure code. For example, anesthesia during a corneal transplant could be billed as 00144-AA (anesthesia for procedures on eye; corneal transplant), if the procedure was personally performed. The same procedure would be billed as 00144-AD if it is part of a group of more than four concurrent procedures that were medically supervised, or as 00144-QK if it is part of a group of two, three or four concurrent anesthesia procedures that were medically directed.

Samantha Mullins, CPC, an anesthesia coder with University of Alabama HSF-MSO Specialty Coding in Birmingham, Ala., and Kolbinger recommend these steps to ensure that the claim accurately reflects personal performance, supervision or direction:

1. Review anesthesia records when you begin coding for the procedure. Proper documentation can be assured only when each anesthesia record is reviewed at the time of coding. Check for accuracy daily, Mullins suggests. Implement a system to help the process flow smoothly so you can avoid mistakes up front.
2. Perform self-audits to verify that cases are being documented correctly, and that you do not exceed four concurrent cases when medical direction is being claimed. Self-audits should be done by in-house staff on a quarterly basis, advises Kolbinger. I also recommend that an outside auditor review records on an annual basis. If your group has a compliance plan in place, check with your compliance officer for the specific auditing requirements.
3. Be familiar with your billing system. Some software will check for medical direction versus supervision on concurrent checks, but others will not. If your software will not check automatically, be sure someone is performing manual overrides as needed to have the claims match the service provided. Our computer program counts concurrent cases for us, explains Mullins, so we can run reports to check our concurrencies. Know what your system can do, and use it to its best advantage.

Kolbinger points out that the provider is ultimately responsible for the claims submitted for reimbursement. Medical record documentation of the services provided must be clear and concise, she says. And as confusing as they can be, Medical billing staff need to understand the concurrency rules. As strange as it may seem, not all private payers consider any overlap in time to be concurrent. Many of the policies set forth are subject to local rules as well. When in doubt, check with your local carrier. Make your requests in writing, and follow up with the carrier if you dont understand their answer.