When the Mode Gets Murky: A Review of Multi-anesthetic Scenarios

Summary: Determining the anesthesia mode can occasionally get complicated—both for the provider and the billing staff. Some situations can lead to unintended consequences, especially where a combined anesthetic is involved. It is important, then, for our readers to recognize the principles for correctly discerning and documenting the anesthesia technique where more than one may be in play.

You're analyzing a single component. It's simple, straightforward and easy to understand. Then, someone comes along and adds an additional component to the mix. Your analysis must now consider more data—not just in terms of the new element but of the newly created compound. Go back to your basic chemistry. Combining two hydrogen atoms with one oxygen atom produces something completely different: a compound molecule that we call water. Introducing an additional element into a situation stirs the pot a bit and can often lead to complexity; but compounding doesn't have to be confounding. We simply need to expand our analysis and think through the new reality.

We recently published an article on the three modes of anesthesia: general, regional and monitored anesthesia care (MAC). The idea is that, for most cases, only one of these modes will be applicable. However, in our review of the anesthesia record, we will sometimes see indications of not one, but two, of these modes. That requires a deeper analysis on the part of our staff to determine what actually happened on the case. There are at least three scenarios that such indications may describe. It is our purpose herein to review these scenarios and, in so doing, provide further clarity on the billing and documentation rules surrounding anesthesia mode.

Intended Combinations

Let's begin by stating the obvious. Yes, it is perfectly fine—from a clinical and compliance perspective—to both deliver and document a combined anesthetic. One that we see from time to time is a general in combination with a spinal. This is where a spinal is meant to augment the general during the operative session. The spinal may also provide postoperative pain relief. However, because the spinal is used for the case, it cannot be billed separately. From a claims-submission standpoint, there is no hindrance to having this type of combined anesthetic, as there is no modifier indicating general versus regional that one must list on the claim form.

Another example of a combined anesthetic we regularly see involves cataract cases. These provide a unique variation from most combined anesthetics. In some of these cataract procedures, the anesthesia provider will apply a retrobulbar or peribulbar block, rather than the ophthalmologist, in the preop holding area. Because the procedure involves delicate work on the eye, a CRNA will often provide a MAC service intraoperatively, usually with some sedation. In such a scenario, both modes should be documented by the anesthesia provider completing the anesthesia record. However, our staff will deem the entire case as regional from a billing perspective, meaning the -QS modifier will not be listed on the claim form. This also removes the possibility of treating the block as a separately payable service. That is, because the block was used to provide an intraoperative anesthetic, it cannot be billed for postoperative pain. Of course, if the block is performed by a non-anesthesia provider, the case will be deemed as a MAC.

Remember also that your anesthesia time in this cataract case scenario would start with the placement of the block—even though it's placed in the preoperative holding area. This is part of the anesthetic, and thus it's billable time. If, after administering the block, the anesthesiologist leaves the patient before the patient enters the OR, the anesthesiologist should denote a stop time reflecting the moment he/she walked away. A second start time would begin once the patient is in the OR with the CRNA.

Though not technically a combined anesthesia mode, it may be helpful to address the situation in which there is a need for two different types of regional blocks. Let's say the patient had multiple injuries involving different parts of the body. In that event, the provider may choose to utilize, for example, a brachial plexus block for the shoulder surgery and a femoral block for the leg surgery occurring during the same operative session. The provider would need to indicate "regional" as to the anesthesia technique, but also describe the two specific block types employed within the appropriate section of the medical record.

Incorrect Characterizations

After auditing thousands of anesthesia charts over the years, we recognize that not every provider is aware of the confusion that can take place when two separate modes of anesthesia are indicated on the anesthesia record. A common example we see is where both "general" and "epidural" are circled on the hard copy record. Without any note as to the purpose of the epidural, we are left to wonder if the provider really meant this as a combined anesthetic or if the epidural had actually been used only for postoperative pain management.

Indeed, years ago, we received a letter from one of the Medicare carriers (now known as Medicare administrative contractors—MACs) stating that they would not pay a particular provider for what he had intended to be a postop pain epidural due to the fact that he had not specified within the record that the epidural was intended only for controlling postoperative pain. In such a case, the carrier stated it would deem the epidural as augmenting the general for the intraoperative case.

The takeaway on this is that when both a general and a regional (e.g., epidural, spinal, nerve block) are listed on the record, and the regional is not intended as part of the anesthetic for the intraoperative case, the provider must clearly convey the purpose of the regional. That is, the provider must overtly state or otherwise indicate that the purpose of the block was for postoperative pain. "Well, what if the block was for postop pain, but I also wanted to use it to augment the general during the case?" In that event, you cannot bill the block as a separate procedure. It's all in the intent. Did you intend it only for postop pain or for both postop pain and intraoperative anesthesia? If the latter, you're looking at a combined anesthetic with no separate payment for the regional.

Inadvertent Compounding

A final category of combined anesthetics that we sometimes see occurs when national bundling rules require us to deem a block—which the provider had documented as being only for postoperative pain—as part of a combined anesthetic. This unintended consequence usually occurs when the mode of anesthesia is listed as MAC. Back in 2013, the National Correct Coding Initiative (NCCI)—the CMS agency which sets the bundling rules for CPT codes—incorporated new verbiage in its Anesthesia Services chapter. The new language included the following excerpt:

An epidural or peripheral nerve block injection administered
preoperatively or intraoperatively is not separately reportable for
postoperative pain management if the mode of anesthesia for the procedure is
monitored anesthesia care (MAC), moderate conscious sedation, regional
anesthesia by peripheral nerve block, or other type of anesthesia not
identified above.

So, if your anesthesia mode is documented as MAC or a regional block (other than epidural or spinal), whatever you intended to be a postop pain block, and documented as a postop pain block, will be regarded as part of a combined anesthetic—where such block is preoperatively or intraoperatively placed. Technically, then, if you provide a MAC service and a medically necessary postop pain block is administered postoperatively, there is no prohibition against separately billing the block. Remember also that many if not most MACs today convert to a general intraoperatively due to the patient losing consciousness where propofol is used. In this interesting scenario, a preoperatively placed postop pain block in a planned MAC case can actually be billed separately where (a) the patient loses consciousness, and (b) the provider remembers to indicate general—not MAC—as the anesthesia mode on the anesthesia record. 

We hope this information will clear up any confusion you may have had concerning combined anesthesia techniques. If you have further questions on this topic, please contact your account executive or reach out to us at info@anesthesiallc.com.