Wiki anesthesia time calculation for facility on a UB- IP

[bstephen]

Hello
I am looking for resources to support what the facility may bill for anesthesia on a UB. I work with auditors who have the belief that the facility may only bill for the technical component therefore this means the OR time and anesthesia time should match most times as the professional component for anesthesia is billed on the 1500. Meaning the time spent by the anesthesiologist in the PACU should be billed on the 1500. Can anyone help me with this concept?

Thanks
Becky

 

[thomas7331]

There really aren't any regulations about how or what a facility may charge for anesthesia, and charges for anesthesia usually do not play a role in determining how as facility claim is paid. Facility billing, coding and reimbursement is a very different animal from professional - unlike physician claims, the charges on a UB hospital claim are meant to reflect facility costs, not procedural work. Your auditors are correct that the facility is billing for the technical costs of the anesthesia, not the professional - time may or may not be a factor in what is charged. The facility's bill will likely be based on the use of the room, the equipment, supplies, drugs, etc. not on the physician's time or work. Facility's may have different methods for determining what they wish to charge, but it's important to remember that facility claim payments are calculated usually based on DRG case rates for inpatient claims, or APC case rates for outpatient, so the charges generally do not affect reimbursement - if a facility is audited, it would be for accuracy of diagnosis and procedural information, not based on what was charged. As far as I know there isn't even a way to report time on a UB claim, and there is no audit or coding requirement that I'm aware of that facility charges must align with anesthesia times that are documented in the record.

 

[bstephen]

Thanks Thomas. Yes, I am in agreement that facility anesthesia only reflects procedural costs. We are being challenged by facilities that are billing for anesthesia time after surgery in PACU. Yes, they place units in rev code 370 fro anesthesia time. I am unable to find any resources to confirm what we both believe to be true.
Becky

 

[thomas7331]

Hi Becky, I am still puzzled as to why this would be an issue since it should not affect payment. There is some CMS guidance that I've seen that, except for a certain set of revenue codes and CPT/HCPCS codes that have to be billed in combination, facilities may choose their own revenue code assignments for charges based on cost centers, not on any coding/documentation requirements. Given that, I would think that the facility would have the freedom to charge their PACU time under any revenue code based on the accounting area that they assign that cost to, so it would not be an error if that was lumped into the anesthesia revenue center or added in based on total time. The units billed on the UB form are not relevant to payment either and don't have to be an accurate representation of the time. I've been out of this area of coding for a while, but if I'm not mistaken, I think the only time measurement that makes a difference to reimbursement is observation hours billed with HCPCS G0378.

 

[bstephen]

It's commercial insurance cases reimbursed at a percentage of total charges. Not Medicare.

Becky

 

[thomas7331]

OK, that makes sense then. But if that's the case, I suspect this is something that's going to be governed entirely by payer policy and contract. In my experience at least, when a payer agrees to a percentage of charge contract, they typically come up with that percentage based on a review of past claims from that provider, and will incorporate a clause that the payer must be notified if the facility changes their charges so that the percentage can be adjusted. So, in other words, payers make themselves well aware of what a facility is going to be charging for services in aggregate over time and set their rates accordingly. The payers will usually revisit the charges whenever the contract renews and will negotiate new rates based on overall payment trends, so there isn't much to be gained from auditing claims one by one or at the line level just to see whether a specific charge is or is not supported by the details of documentation the way you would in a fee-for-service situation. And also to consider is that even if the PACU charges were to be excluded from the anesthesia revenue code charge, the facility would likely still claim those charges under a different revenue code, so the total claim charge would remain the same and not affect payment, even on a percentage of charge contract.

All that said, I still don't think there is coding or regulatory guidance that says that a facility's anesthesia charges have to be based on time the physician's anesthesia time, but perhaps someone else on the forum can point to something. A revenue code is a cost center, not a service code, so it may include items that are not part of a professional service and there is no expectation that the units would need to match the professional claim record.