June 4, 2018

The sessions on anesthesia coding and documentation at the Advanced Institute for Anesthesia Practice Management (AIAPM) in Las Vegas offered timely insights into the challenges anesthesia groups face as they transition to electronic anesthesia records (EARs) and anesthesia information management systems (AIMS).

The examples provided by Devona Slater of Auditing for Compliance and Education and others reinforced the importance of ensuring that those making critical coding decisions have all the necessary pieces of information. EARs clearly provide more information in a more legible format, but finding it all in the more extensive records now being generated by these systems is not always easy.

We refer to the coding process as extract coding for a reason. Depending on the type of surgery, different pieces of information must be compiled and assessed for different parts of the record. Colonoscopies, for example, require a pre- and a postoperative diagnosis. The coder must be able to attest to the fact that the code assigned for billing meets all the necessary requirements. Did the provider document, for example, that the interscalene block was performed at the request of the surgeon? And where is that noted in the record?

It used to be that a one- or two-page anesthesia record contained all the necessary information. But as clinical documentation requirements have expanded, coders must be able to access the preoperative note, intraoperative note, operative report and postoperative note. Depending on the system and the specific terms that have been agreed to, some or all of this information may not be readily available to the billing staff, and this can prove problematic.

Remember that from a compliance perspective, a claim to an insurance company is a request for payment. Submitting a claim is tantamount to an attestation that it is a complete and accurate representation of the service provided. Moreover, irrespective of who prepared the claim, it is the provider’s responsibility. If a payer questions a claim, it is the provider who will be held accountable.

While the vendors of these automated record systems would like to have providers believe that they simplify the coding and billing process, this is simply not the case. In fact, in most cases, they create an overlay of logistical complications that never used to exist. As in so many things, careful implementation planning and oversight is critical to compliance. Providers migrating to EARs are always advised to inspect, not expect. In other words, don’t assume that all the documentation captured by the EAR will support the requirements of billing.  It is essential for your billing and coding team to have access to all the critical elements of a case in order to ensure accuracy and completeness and submit the claim promptly to the appropriate payer.

The following checklist of critical data elements should serve as the starting point for implementation and ongoing audits:

• A definitive identification of the patient and the date of service
• Confirmation of the provider(s) of record
• A postoperative diagnosis (Endoscopy cases also require a preoperative diagnosis.)
• A postoperative description of the surgery
• The anesthesia start and end times
• Any other separately billable services provided, such as invasive monitoring, nerve blocks or guidance charges
• Provider signature

For more information, see the Statement on Documentation of Anesthesia Care from the ASA Committee on Quality Management and Departmental Administration.

We want to hear from you.  Do you have a topic you would like to see covered in an ABC eAlert?  Please send your suggestions to info@anesthesiallc.com.

With best wishes,

Tony Mira
President and CEO