Anesthesia Documentation from a Compliance Perspective

Summary: 

The methods by which anesthesiologists and anesthetists memorialize their services for billing and clinical purposes is changing—and mostly for the better. Certain electronic record options provide many advantages, though a few shortcomings should be noted. Whether utilizing paper or electronic records, the primary task for the provider in his/her medical record documentation remains the same: consistent compliance with payer requirements.

Virtually any compliance in-service begins and ends with a statement about the importance of accurate and complete documentation. It is an admonition that often falls on deaf ears. Whether they complete paper anesthesia records or complete the requirements for electronic anesthesia records (EARs), most providers will assure you they have accurately documented the clinical services they provided and assume that this is good enough. In most cases, this is true. It is the exceptions that put providers at risk, however.

Out with the Old

Anesthesia record-keeping is undergoing a profound transition as more facilities implement EARs. The paper anesthesia record is an arcane document if ever there was one. It is intended to identify the patient, the procedure and the diagnosis together with a grid that tracks the provider's and the patient's response to the significant events of the surgical procedure. Because it is completed by the provider during the anesthetic, one must always wonder how accurately it reflects the actual details of the case. Details, such as blood pressure readings, are often noted from memory.

There used to be a tradition that had providers completing two documents for each case: the actual anesthesia record, a required medical-legal document, and a separate charge ticket or billing slip. Since the potential audience for the anesthesia record was attorneys intent on finding fault with the care, it was often completed in the providers' sloppiest hand-writing, while the billing ticket that was necessary for getting paid often looked as if it had been very carefully printed. In both cases, however, the forms were part record and part mnemonic.

Each group practice is unique and their record template is often customized or configured so as to remind providers which details of the case are most important to note either from a clinical or a billing perspective. Although many practices historically favored the separate billing slip, as it gave the provider the ability to keep track of what was billed, duality is often a problem. When the forms do not agree, which is correct? The fact is that only the anesthesia record will be viewed as substantiation of the claim. Again, this is because the billing slip—while a helpful reference for some groups—is not a medical record from a legal perspective.

A Necessary Transition

We have encouraged our clients to move to a single record for compliance reasons. Such a transition has not occurred in a vacuum, however. The typical anesthesia record must now support a variety of clinical and administrative requirements, not the least of which has been pay for performance (P4P), now known as quality indicators. As the requirements expand, form real estate becomes more precious, and the likelihood that all records will be completed in a clear and legible manner diminishes.

This has proven to be a particular challenge for coders who must parse out the actual start and stop time, the exact surgical procedure, the diagnosis, and any additional services, such as invasive monitoring or nerve blocks that should be billed. There are a number of crosswalk issues, such as identifying if the abdominal procedure involved the upper or lower abdomen. Just indicating that a patient had a knee arthroscopy, for example, is not enough to indicate whether the procedure was surgical or diagnostic. We do our best to educate our client providers with regard to the subtle requirements of anesthesia billing, but old habits die hard. Too often, providers default to the path of least resistance. Our commitment to provider behavior modification is ongoing, and we consider provider participation in our in-service sessions a critical aspect of our commitment to compliance.

Not Without Challenges

We are seeing many of our clients migrating to EARs. We encourage this development and have provided a special team of implementation specialists to assist our clients. The good news is that the end result is a record that should be complete, accurate and, most of all, legible. The bad news, or the challenge, is that, because these electronic interface systems capture so much more data from the monitors, the average record can now be as much as 20 pages. This makes it that much more difficult for coders to read all the details of each record to identify billable elements.

The use of computer technology to generate anesthesia records imposes its own set of rules and parameters on the process. Records may include a number of edits, otherwise known as soft and hard stops, to ensure that necessary details are captured. While providers used to be able fill out a paper record and drop it off for billing, the EAR requires that all the criteria necessary to close the record have been met before submission to the billing office.

A critical piece of the billing process is the determination of the surgical procedure that was actually performed and the most complete post-operative diagnosis; and, for endoscopic cases, we must identify both the pre-op and post-op diagnosis. In most electronic record systems, procedure and diagnosis is pre-populated based on how the case was scheduled. The problem comes when the system does not include a means for the provider to update procedure and diagnosis details based on what actually happened on the case.

Outweighing the Cons

It is our understanding that, despite some initial trepidation, most clients are reasonably happy with their EARs once they are fully implemented. Certainly, such systems make it much easier for us to obtain records for all the services provided. So, on balance, we view the continued implementation of EARs as a positive development. We are always reminded, however, that no system is perfect, and strange things can happen when software gets updated.

Let us not forget that billing for anesthesia services and getting paid appropriately is itself in a constant state of evolution, as new services are being developed and new payer guidelines are being implemented. From a documentation perspective, the challenge is still the same: ensuring that the clinical record accurately reflects the services provided. If you have questions about the system you use, please feel free to contact your account executive or reach out to us at info@anesthesiallc.com. Remember, as well, that is important that you contact us as soon as you discover that your group will be transitioning to an electronic record. We can provide invaluable assistance to the implementation team to ensure the system is able to efficiently and accurately capture all necessary data elements.