September 7, 2021

It’s all in how you finish.  Sprinting out of the gates at the sound of the starting gun during a local marathon will put you in the lead for a while.  You’ll look pretty good in comparison to all your competitors, at least for a short time; but, because you expended so much energy at the outset, you’re likely to quickly tire and wind up finishing dead last.  In any endeavor we undertake, the ideal is to maintain excellence from beginning to end.  That is, we should not flag or let up just because we’re nearing the time of completion.  We should finish strong.

That standard surely translates to the anesthesia context.  It’s not enough to perform a thoroughgoing pre-anesthesia assessment or to perfectly deliver the intraoperative anesthetic; it is also important to adhere to the clinical and compliance expectations surrounding the end of the case.  That includes knowing what should be performed, what must be documented, what is bundled into the anesthesia fee and what can be billed separately.  In today’s alert, we will be examining all of these issues.

Time Notations

Okay, the surgery has just ended, but that’s no reason to let up on your time indications.  You can continue to chart vitals, if practicable, to the time you transfer care.  Alternatively, it would be helpful to add other time notes if an EMR is not already doing this automatically.  We often see, upon audit, providers failing to sew up the end of the case as it concerns time.  Often, there will be a gap in the time documentation starting around the end of the procedure.  For example, let’s say the surgery ends at 0915.  We’ve seen cases where that would be the time of the last vitals marks on the anesthesia graph.  The next time we see is the stop time at 0930.  That represents a gap of 15 minutes in which the anesthesia provider’s time is not accounted for from a record documentation perspective.  According to Medicare, this is too large of a time gap, and the payer could, upon audit, require recoupment of a time unit in such a circumstance.

In order to avoid this kind of time deficiency, it will be helpful to consistently add the following time notes to your end-of-case documentation: (a) surgery end time, (b) OR out time, and (c) PACU in time.  These time notations will help to fill in any missing gaps in the time story, leaving an auditor nowhere to go in their error quest. 

Remember also that, if your time in PACU is extensive beyond the norm, Medicare is also scrutinizing that.  Some years ago, the federal payer’s internal research revealed that seven minutes represents the normative amount of time for an anesthesia provider to be in the PACU before transferring care.  While there is no hard and fast rule on PACU time, this does provide us with an insight into what Medicare auditors may be looking at when it comes to your claimed anesthesia time toward the end of a case.  Remember, however, that Medicare’s finding is based on an averaging of PACU times across all case types.  Medicare understands that not all procedures lend themselves to exactly seven-minutes of recovery time.  It may normally take more time in PACU for a heart procedure than a cataract.  So, if you spend an inordinate amount of time in the recovery area than you normally would for that case type, it’s a good idea to provide an explanation for the extra time within the Comments section of the record.

Typical Postoperative Care

The National Correct Coding Initiative (CCI) is a Medicare program that provides guidance on bundling.  It lays out what smaller services are components of a larger, overall service, as reflected by a single CPT code.  One of the items that the CCI lists as integral to every anesthesia code is “post-anesthesia recovery care.”  Though not further defined, this would seem to include—at the very least—the time you spend with the patient in the recovery room prior to you transferring care to the PACU nurse or ICU personnel.

In addition, any typical post-surgical visit with the patient after transfer of care that has the purpose of seeing how the patient is recovering from the effects anesthesia would be bundled into the anesthesia base units, as reflected by the anesthesia code on the claim form.  There would be no separate payment for the normal post-anesthesia visit.

The Medicare State Operations Manual, a set of instructions to hospital surveying organizations (e.g., Joint Commission), specifies that the anesthesia service must include a post-anesthesia assessment, which cannot begin until the patient has the ability to participate in the process.  If the patient cannot participate, those circumstances should be documented within the assessment.  The anesthesia provider has 48 hours (from entering the recovery room with the patient) in which to complete the assessment.  Again, this is a service that is bundled into the anesthesia code base units and not separately payable.  The assessment must include notations relative to the following elements:

• Respiratory function, including respiratory rate, airway patency, and oxygen saturation
• Cardiovascular function, including pulse rate and blood pressure
• Mental status
• Temperature
• Pain
• Nausea and vomiting
• Postoperative hydration

Unusual Circumstances

Sometimes issues arise after the case has ended.  The question is, can addressing those patient issues lead to additional billing?  Let’s take a look at a couple of scenarios.

Vent Management.  If the anesthesia provider transfers care and chooses to keep the patient on a ventilator and then sees the patient later that day to assess and extubate, the anesthesia provider cannot bill for that management.  However, if the anesthesia provider hands the management off to another specialty and is then called back because of patient status, the management becomes separately billable.

If the patient remains ventilated through the next day due to ongoing concerns or issues and the anesthesia provider sees that patient for vent management and extubation, the anesthesia provider can bill for the management.  However, where the vent management is part of a critical care service being performed by the anesthesia provider, it would not be separately billable, as the vent management would then be inclusive of critical care services.

Return to PACU.  If, after a case has been transferred to the PACU nurse, the anesthesia provider is called back for the purpose of providing anesthesia care, no new case would be billed.  The reason is there is no new pre-anesthesia assessment, no new induction and no new procedure.  Our position is that, in such circumstances, we would simply add minutes to the total anesthesia time reflecting the provider’s additional time on the case.  The provider should add a note in the Comments section of the record explaining why it was necessary to come back and resume the case.

Part of the reason for our taking the above position is the verbiage found in the anesthesia section of the aforementioned Correct Coding Initiative.  According to the CCI, “The anesthesia practitioner assumes responsibility for anesthesia and related care rendered in the post-anesthesia recovery period until the patient is released to the surgeon or another physician.”  A return to the PACU for a continuation of anesthesia would be tied to the original case and simply involve an extension of that case.

If you have further questions related to post-anesthesia care and billing, feel free to speak with your account executive or reach out to us at info@anesthesiallc.com.

With best wishes,

Tony Mira
President and CEO