It’s About Time: More Anesthesia Time Tenets

Summary: 

Start time and stop time are not the only time issues that anesthesia providers must consider as they attempt to successfully document the medical record. Today's article provides helpful guidance on some additional time issues that many providers are currently overlooking.

Earlier this month, we began a multi-part primer on anesthesia time, with part one focusing specifically on the basics of anesthesia start time and stop time. In this part-two article, we will turn our attention to a few other issues involving time that anesthesia providers must master in order to fully comply with the billing rules. It may be surprising to some to see just how many time elements come into play in an anesthesia case beyond just start and stop time. Understanding and consistently following all of these time tenets will be the key to keeping you in good stead with prospective auditors, as well as preventing your billing staff from sending you requests for further clarification. With that said, let us now turn to our time topics for today.

Time Rounding

There are occasions when we will notice a particular provider who shows a tendency to list both their start and stop times in five-minute increments. That is, they will list times ending in either a 0 or 5, rather than listing the exact start time (e.g., 0803) and precise stop time (e.g., 1032). This deficiency is generally going to be linked more with hard-copy records than with electronic records (EMRs), due to the EMR's time functionality. Listing start and stop times in five-minute increments makes it look like you are rounding minutes up or down in order to gain extra minutes and thus score an extra time unit on the case. As Cody P. Jones, CPA, MBA, ChFC, writing for the American Academy of Professional Coders, explains:

Because Medicare recognizes 15-minute time units and pays to the tenth of a unit (e.g., 1.5 minutes), physicians should report exact minutes for both start and stop times. Too often, groups round to the nearest five-minute increment, or worse, estimate the time involved based on past experience. A good indication of potentially inappropriate rounding is if more than 20 percent of a practice's start and stop times are fixed on five-minute intervals.

This is one reason why such time accounting should be avoided. Another is that it can create confusion in terms of concurrency calculations; and then there is the potential problem of contradictory times when compared with other medical documentation (e.g., nurses notes).

We are not suggesting here that you should avoid listing a start time or stop time ending in a 0 or 5 if that accurately reflects when the case either started and/or ended; but the fact is that auditors are aware of the chances, from a percentage basis, that a case will have both a start and stop time ending with those numerals. If, upon reviewing a sampling of your records, they see that you are outside of the norm, they may assume you are engaged in fuzzy time accounting, which could lead to negative action. So, the best policy is to simply list the exact start time and stop time—every time.

The chart below is a typical tracking tool. It indicates the percentage of Medicare cases by provider where the times are divisible by five. In this example there is only one outlier.

Relief Time

This time issue will only come into play where a case is handed off to another provider at some point between the anesthesia start time and stop time. For concurrency, compliance and billing purposes, we need to know not only who came in to relieve the previous anesthesia provider on the case, but when that relief took place. Therefore, in addition, to his/her signature, the relieving provider should list the time when he or she took over care. It will be helpful for the provider who is handing off the case to list his or her handoff time, as well.

In a surgical anesthesia case (that is, one not involving a labor epidural), and in absence of any payer guidelines to the contrary, we will typically bill out a handoff case in the name of the provider who had the most time on the case. So, if in a personally performed or medically directed case, Dr. Smith (who initiated care) was on the case for 36 minutes, and Dr. Jones (who came in to relieve) provided the final 68 minutes of care, we would bill the entire MD/DO portion of the case under Dr. Jones. Accordingly, listing relief signatures and relief times is critical to the billing process in such cases.

Inordinate PACU Time

Occasionally, a provider will be faced with an unusual anesthesia case that will require spending an inordinate amount of time with the patient in the PACU. It is important to know when you can bill for such time and how to support this time in the medical record. Medicare once performed an internal study that revealed the typical time spent in PACU by an anesthesia provider is seven minutes. This finding was not meant to be set as some arbitrary government threshold, but it does show that Medicare is looking at average PACU times in connection with anesthesia claims.

Obviously, every case is different, requiring a varying amount of time and attention on the part of the anesthesia provider while the patient is in the PACU. In addition, each type of case may come with a different average of PACU time. For example, you may typically spend more time in the PACU with a patient who has just gone through open heart surgery than one who had a minor procedure.

The key here is to know what your typical time in PACU is for each type of case; and, if you see that you are needing to spend an inordinate amount of time in the PACU for that case type, you should drop a note in the comments section of the record explaining why you are claiming that unusual amount of minutes in the recovery unit. This will help to keep at bay a prospective auditor who is paid to find suspicious claims for time. As long as there is medical necessity for continuing to provide care, and that necessity is documented, the time should be billable. What you must avoid is engaging in a pattern of claiming extended time in PACU. That will certainly raise red flags with payers.

What Time Is It?

There are a couple of smaller time issues we occasionally see that can nevertheless lead to big problems. They both involve using different mechanisms for designating start time versus stop time. The first of these involves using 24-hour, or "military," time mode for the start time, let's say, and then reverting back to a normative 12-hour time mode for the stop time. This inconsistent use of time modes can lead to a misinterpretation of the intended times on the record, which may then lead to highly inflated claims in terms of total minutes. For this reason, we recommend the consistent use of military time (e.g., "1710," instead of "5:10") for both start time and stop time designations.

A similar time issue that involves an inconsistency in start and stop time accounting involves the use of different timepieces for each end of the case. That is, you may be using the time on your watch to list your start time, but you may be going by the clock on the PACU wall in the listing of your stop time. If these two time devices are off by a few minutes, you will be errantly adding or subtracting billable minutes as a result. So, here again, we recommend consistency. You should utilize the same timepiece, if possible, for both start and stop time documentation. As with many time issues we've discussed, these two potential time deficiencies will be less likely to occur where an EMR is being utilized.

In Times to Come

The foregoing represents some of the primary time issues with which anesthesia providers must familiarize themselves. In coming weeks, we will present additional articles related to time, including labor epidural time and time related to separately billable procedures. This multi-part series of articles does not claim to capture every nuance or every contingency involving time, but rather attempts to present the basics required for properly understanding and documenting this data component so critical to the specialty of anesthesia. If you want us to assess how these time-specific issues might impact your practice, we would be glad to assist you. Please reach out to your account executive, or you can contact us at info@anesthesiallc.com.