Counting the Minutes: A Fresh Look at Anesthesia Time
Summary:
Not every anesthesia provider is on the same page when it comes to determining and documenting anesthesia time. Because of this, some providers may be losing money, while others are in violation of the billing rules. In this first installment of a two-part article, we will focus on the appropriate way to define and document anesthesia start and stop time.
As lockdowns are easing and elective surgeries are expanding, it may be a good time for anesthesiologists and anesthetists to refamiliarize themselves with one of the foundational components of their claims for services: anesthesia time. While some of our readers are already proficient at understanding and implementing such concepts as "start time" and "stop time," many are not. In fact, it is often surprising to see that in a group of anesthesia providers, who have been working together for years, not all are on the same page as to when they should begin or end anesthesia time. Furthermore, the beginning and end of a case are not the only issues the anesthesia provider must consider when it comes to time.
It should be remembered that this is not just a compliance concern. Many providers are potentially leaving money on the table either by not fully recognizing all the minutes to which they are entitled to bill or by not sufficiently documenting such time. Because confusion and inconsistency continue to be observed as it concerns various time-related issues within anesthesia practices, the following two-part primer is offered on anesthesia time. This first article will concentrate on the basics: anesthesia start time for surgical/procedural (non-OB) cases.
Beginning and Beginning Again
The following definition of anesthesia time is found in the Medicare Claims Processing Manual (MCPM), Ch 12, Sec 50G, as well as the ASA's Relative Value Guide (RVG):
Anesthesia time is defined as the period during which an anesthesia practitioner is present with the patient. It starts when the anesthesia practitioner begins to prepare the patient for anesthesia services in the operating room or an equivalent area and ends when the anesthesia practitioner is no longer furnishing anesthesia services to the patient, that is, when the patient is safely placed under postoperative care.
Based on the first sentence in the above definition, the first maxim of anesthesia time billing is that you cannot bill such time if you (or a member of your group) are not physically present with the patient. The next sentence deals with anesthesia start time. Notice the phrase "begins to prepare." The phrase is not "begins the anesthesia," but rather "begins to prepare the patient for anesthesia services." That can have a rather broad range of meaning. Most compliance experts, in consultation with CMS, OIG and Justice Department officials, have indicated that services, such as placing an IV or administering Versed in the pre-op holding area (PHA), would fall under the "begins to prepare" standard. Accordingly, the anesthesia provider could reasonably list a start time concurrent with such PHA activities.
When listing a start time concurrent with a PHA preparation activity, we strongly recommend you list separately on the anesthesia record a note indicating what you were doing at the claimed start time (e.g., "0730 – Administered Versed"). Many electronic records (EMRs) will be able to easily facilitate such a time-stamped note in the Events section. Be advised, however, that some PHA activities cannot be tied to anesthesia time, including (a) patient ID, (b) patient assessment, and (c) chart review. The time it takes you to perform these tasks are bundled into the base units of the anesthesia code for which you are already being paid; so, you cannot bill for their time.
Sometimes, you will actually be starting the primary case anesthetic in the PHA, such as with a regional block, which raises another potential time issue for the anesthesia provider. Let's say you start the block in the PHA at 0730 and leave the patient at 0740, then meet the patient in the OR at 0800. In this scenario, your anesthesia start time is 0730, not 0800. However, what do you do about the 20 minutes you were not present with the patient in the PHA? The anesthesia time definition we previously reviewed clearly indicates that this 20-minutes period cannot be billed. This means the case will necessarily involve the combining of discontinuous time blocks in order to arrive at a total anesthesia time. The MCPM and RVG definition of anesthesia time, referenced above, goes on to address this discontinuous time principle:
Anesthesia time is a continuous time period from the start of anesthesia to the end of an anesthesia service. In counting anesthesia time for services furnished, the anesthesia practitioner can add blocks of time around an interruption in anesthesia time as long as the anesthesia practitioner is furnishing continuous anesthesia care within the time periods around the interruption.
From a practical perspective, this means that anesthesia records should have the capability to record at least two sets of anesthesia start and stop times. For example, in the scenario presented above, the first start time would be 0730, while the first stop time would be 0740. The second start time would be 0800, and the second stop time would be whenever the case was transferred over to the PACU nurse (which we'll address in more detail below). Many of our groups have incorporated multiple sets of start/stop time fields on their hard-copy record or alternatively have capabilities within their EMR to list multiple sets of start and stop times.
Putting a Stop to This
In one of the classic movies about college kids run amok, an over-zealous ROTC officer, upon facing a disrupted homecoming parade at the hands of a notorious fraternity, shouted "Let's stop this now," as he proceeded to load a round into his rifle. At some point, all good things must come to an end, and this is true for an anesthesia service, as well. Determining when that is, however, is another matter.
According to the MCMP and RVG definition, referenced above, anesthesia stop time is that moment when "the anesthesia practitioner is no longer furnishing anesthesia services to the patient, that is, when the patient is safely placed under postoperative care." The shorthand term for this description is "care transfer." In a nutshell, then, your care transfer time IS the anesthesia stop time. This is why some groups have amended their record templates to replace "End" or "Stop" time labels with a "Care Transfer" time label. This allows there to be no question in the mind of an auditor that the time listed in this field is the true stop time, as it conforms to the government's own definition of stop time.
For those of you who utilize an EMR, some records will come with a standard field labeled, "PACU Transfer" or similar verbiage. This is meant to capture your PACU out time—which is synonymous with the care transfer, i.e., stop, time. If your EMR has both a PACU transfer/out time field and a stop time field, make sure that the same time is in both fields, unless there is a functionality within the EMR that will not allow this. In that event, please make sure to communicate to (a) all the members of your group, and (b) your account executive which time field is meant to capture the true stop, i.e., care transfer, time.
If your record does not contain such fields as "Care Transfer" or "PACU Out," then you may want to consider dropping a separate timed note within the record that further defines your claimed stop time. For example, if the time you listed in your stop box/field is 0930, you might state in the Events or Comments section: "0930 – care transfer." While such notes are not required for billing, they will fend off any potential questions of an over-zealous auditor.
Time issues begin with a proper understanding and application of anesthesia start and stop time. However, this is only the beginning of what providers must consider as it concerns anesthesia time, generally. In part two of this primer, which will be published later this month, we will look at several other issues concerning time that we trust will provide a greater measure of clarity for our clients. If you have questions about how your group is performing as it concerns proper documentation of start and stop time or how to configure your record template to more adequately capture start and stop time, please reach out to your account executive or email us at info@anesthesiallc.com.