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Sweat the ‘Small’ Stuff: A Checklist for More Thorough Anesthesia Documentation
March 26, 2018
We review some aspects of clinical documentation to which anesthesia practices should pay close attention.
No other specialty has a clinical document like the anesthesia record. The anesthesia record must serve as superbill, clinical record, quality tool and medical-legal document. In addition, each anesthesia practice has its own customized documentation tool that must communicate the details of each anesthetic to the billing staff.
The following are some of the aspects of clinical documentation to which practices should pay close attention:
Time: The anesthesia record must clearly communicate who was responsible for the patient at any given moment in time. Most significantly, an anesthesia service that does not indicate start and stop times cannot be billed. In general, anesthesia time represents a continuum of care during which there is a relationship of dependence between patient and provider.
Documentation should begin with the first administration of a drug or agent that changes the patient’s physiology, but there are some significant exceptions and qualifications. Induction time must be clearly noted as this is an essential element in determining whether the time to insert invasive monitoring or perform nerve blocks for postoperative pain is included in the anesthesia time or carved out.
Medical direction and concurrency: Many providers confuse these two terms. Concurrency indicates the number of cases an anesthesia provider is responsible for at the same moment in time. A one-minute overlap constitutes concurrency. Providers need to be attentive to exactly when one case ends and another starts.
Medical direction may involve concurrency but it refers to the specific payer guidelines for defining the members of the anesthesia care team. From a billing perspective the record must clearly show which provider or providers were responsible for the case at any moment in time.
Endoscopy: The explosion of anesthesia’s involvement in endoscopy cases has resulted in a new set of codes and some arcane coding requirements. Preoperative and postoperative diagnoses should be documented on the anesthesia record. In 2018, documentation affects not only the modifiers used in coding, but also the American Medical Association’s Current Procedural Terminology (CPT) codes reported. As discussed in our November 13, 2017 eAlert, CPT codes 00740 (anesthesia for upper GI procedures) and 00810 (anesthesia for lower GI procedures) were eliminated and replaced in 2018 with five new codes felt to more accurately describe the procedures being performed:
00731: Anesthesia for upper GI (EGD)
00732: Anesthesia for endoscopic retrograde cholangiopancreatography (ERCP)
00811: Anesthesia for lower GI (not otherwise specified)
00812: Anesthesia for screening colonoscopy
00813: Anesthesia for upper and lower GI during the same session
Surgical procedure documentation: One of the most challenging aspects of anesthesia billing is the requirement to navigate from CPT surgical codes to ASA codes and their anesthesia base values. While there is a one-to-one relationship for most surgical procedures, at least 850 surgical CPT codes have a one-to-many relationship to various ASA codes depending on the location of the surgery. Integumentary procedures, for example, are worth five units if they involve the head or neck or a patient in the prone position; otherwise they are worth three units. Making sure this necessary detail is communicated to the coders is an essential but often overlooked aspect of the documentation process.
Postoperative pain blocks: Postoperative pain blocks and catheters have specific documentation requirements. Documentation should include:
- Date of service
- Block/catheter performed (nerve blocked, not approach)
- Purpose of performing the block (e.g., for postoperative pain management)
- Who requested the block (e.g., per surgeon’s request, per patient’s request, etc.)
- Clearly document the catheter placement to distinguish it from the means of anesthesia administration.
- Document the use of any imaging services, including an outcome statement related to the imaging used. Document whether the image is stored. This service will be coded and billed separately.
- Start and stop times and induction time (to determine billable status of non-anesthesia procedures).
- Note: When performed with monitored anesthesia care (MAC), a postoperative pain block or catheter is not billed separately unless the block/catheter is performed after the MAC stop time.
Imaging guidance documentation: Two requirements must be met in order to bill separately for imaging guidance in anesthesia: 1) the images must be saved or on file so they can be easily retrieved at a later date; and 2) a “written report” indicating what the provider visualized must be included in the record. Documentation that the image is saved, on file, in the patient’s chart must be provided.
Cosmetic/Insurance split cases: The typical case results in a single claim to a specific payer but cosmetic cases may involve billing both the insurance and the patient. Feedback from anesthesia providers indicates that they often do not know when a case is a cosmetic/insurance split case. In order to process the charges correctly and bill correctly, documentation must support all of the procedures performed, the total time for each procedure, which procedures are considered cosmetic and which are considered insurance.
We hope this brief and cursory review of anesthesia billing challenges will prompt you to review your current documentation. All anesthesia records should be reviewed on an annual basis. For assistance and recommendations please contact your ABC account executive.
With best wishes,
President and CEO