June 25, 2018

One of the factors that causes concern in billing is the term “concurrency.”  There are providers who believe that concurrency is synonymous with medical direction, that it only applies to physicians or that it only applies to certain insurance companies.  All three of these assumptions are not true.  Concurrency has nothing to do with medical direction.  Concurrency applies to all provider types.  Concurrency applies to all insurance companies.  As a matter of fact, concurrency applies to all anesthesia cases performed by any type of provider.

What is concurrency?  It is the number of cases a provider is involved in at the same exact moment.  When looking at concurrent cases, one has to look at every case a particular provider is involved in and every minute of all cases, and decide how many cases are going on at the same minute for that provider.  (Note: labor epidural cases do not apply to concurrency.)

The different types of providers we are referring to are staff physicians, CRNAs, anesthesia assistants (AA), residents and student CRNAs (SRNAs).  We will discuss what concurrencies can be billed for the staff physician first and then we will discuss the nonphysician anesthesia providers.

Staff Physician

A staff physician who is doing their own anesthetic case can only be in one place at a time.  This gets down to the actual minute.  From a billing for time perspective, a staff physician cannot end a case in the same minute they start a case.  For example, if you stop your time for patient 1 at 0806 your next case cannot start until 0807.  This is because we cannot bill the same minute twice.

If a staff physician is medically directing any of the other categories of providers and is expecting payment at the full allowable rate, there are restrictions on how many concurrent cases the staff physician can be involved in. (This is assuming that all of the other criteria for medical direction are met.)

If the staff physician is medically directing CRNAs or AAs, the staff physician can have up to four concurrent cases.  This means that in every minute of time the staff physician can only be responsible for up to four cases.  When it comes to residents, the staff physician can be responsible for two cases simultaneously.  This is based on Medicare payment practices as well as rules of the Accreditation Council for Graduate Medical Education (ACGME) for anesthesia resident education.  When it comes to SRNAs, the staff physician can only be responsible for two cases.

CRNA

A CRNA can only be in one place at a time just like a staff physician.  There is one exception to this.  If the CRNA is not being medically directed by a staff physician, the CRNA is able to be responsible for two SRNAs.  Special rules for responsibility and billing of time have to be considered.  This is the only exception that applies to any provider type.

Resident and SRNA

Both of these provider types can only be in one place at a time.

A great deal of the above is common sense, but we see a number of instances of minimal time overlaps. How does this happen?  A common reason is that clocks in the OR are not synchronized.  If you have an EMR, it may not be in all locations in which anesthesia providers work.  You drop the patient off at 0806 on one clock and when you get to the next clock it says 0804.  For this reason, it has always been ABC’s recommendation to use one time piece when denoting anesthesia start time and anesthesia stop time. As shown above, it is recommended that a 24-hour clock be used to document time to make sure there is no confusion between AM and PM.

It is also important to remember that if a staff physician is medically directing, that staff physician is not allowed to do their own anesthesia case.  Lastly, staff physicians cannot start a case that they are going to medically direct without having a nonphysician anesthesia provider available.

In conjunction with the above, providers often ask whether an EMR helps with making sure that time is entered accurately. The answer is twofold.  If the EMR is at all areas of the hospital where anesthesia on a particular patient is performed and you use the clock on the EMR, you should have no inadvertent time overlaps.  Some EMRs actually check for concurrency.  On the other hand, if you do not close the record properly (enter stop time), the case that is ending could go on beyond the time you have started the next case.

With best wishes,

Tony Mira
President and CEO