An Early End: Anesthesia Considers Canceled Cases

Summary: Not every anesthesia case ends as planned. Some never get off the ground. In such circumstances, are there still opportunities for reimbursement? Today's article explores those possibilities.

All good things must come to an end, or so the saying goes. The problem arises when they come to an end too soon—suddenly and unexpectedly. Often times, there is little consolation for the rainout of a barbecue or the cancelation of a concert or the sudden loss of a once beautiful relationship. Abrupt endings are rarely desirable; but, every now and then, they can come with a slice of solace. That circumstance particularly applies where the anesthesia provider finds him or herself faced with a canceled case.

Everyone's ready. The preparations have been made. Mental processes are heightened and everybody's bringing their A-game. A patient is about to undergo surgery and clinicians of all kinds are gearing up for the task at hand. The anesthesia team, in particular, are doing all they can to ensure the medication levels are just right to keep the patient both comfortable and alive. That's when you hear it. The case has been scrubbed. Something unforeseen has happened. There could be many causes for this. It may be that the surgeon was running late or began to feel ill in the middle of the case. It could be that the anesthesiologist's or anesthetist's pre-anesthesia assessment (PAA) revealed indications that the patient was not a candidate for surgery—at least not for that day. Whatever the cause of the cancelation, there is nevertheless a silver lining in this otherwise dark cloud. Today's article will focus on canceled cases and what anesthesia practitioners should do in response.

Cancelation After Induction

There are few things more frustrating to an anesthesia provider than doing all the workup on a patient and carefully administering the anesthetic only to have the case abruptly ended. However, the provider can take comfort in the fact that all is not lost. There is still the potential for getting paid for all the work and time that he or she expended. For cases canceled after induction of the anesthetic, we will bill the full base units and any time units reflecting the number of minutes you spent on the case up to the point it was canceled. For example, if you spent 15 minutes in a cardiac case that was worth 25 base units, we would be able to bill a total of 26 units (base + time) for that surgical session. This claim submission protocol is also found in the billing policy of one of the Blues, as reflected in the following excerpt:

If the procedure is cancelled or discontinued after general or regional anesthesia induction has occurred, report the following: The appropriate American Society of Anesthesiologists (ASA) code corresponding to the surgical procedure plus the time expended, in minutes, providing the anesthesia services.

Under these circumstances, we will need you to document (on the anesthesia record) the following: (a) an indication that the case was canceled, (b) why the case was canceled, and (c) when it was canceled. All other normal indications on the record should be present (e.g., times, diagnosis, procedure, signature, vitals marks).

Cancelation Before Induction

Some may be surprised to learn that a case canceled after induction is not the only cancelation scenario that provides an opportunity for reimbursement. The National Correct Coding Initiative (CCI) is a Medicare program that determines what services are deemed inclusive within a comprehensive service that is reflected by a single CPT code. In the introductory paragraphs associated with the Anesthesia section of the CCI's Policy Manual, we find the following entry:

If a surgery is canceled, subsequent to the preoperative evaluation, payment may be allowed to the anesthesiologist for an Evaluation & Management (E&M) service and the appropriate E&M code may be reported. (A non-medically directed CRNA may also report an E&M code under these circumstances if permitted by state law.)

An E&M service is essentially akin to a doctor visit. Such services include documenting the following components: patient history, patient exam and medical decision-making (MDM).That is essentially what you are denoting whenever you generate your pre-anesthesia assessment. That acts as an E&M service, except that this service is typically bundled into the greater anesthesia service. However, if the anesthesia service is canceled prior to induction, all that is left is the pre-anesthesia assessment. That now becomes payable. It should be pointed out here that an issue could arise if the patient undergoes the procedure within the following few days. If that occurred, the previously performed assessment could be deemed bundled into the rescheduled anesthesia service.

Presumably, there will be no anesthesia record in this circumstance. Therefore, we will need you to send us your pre-anesthesia assessment so that we can determine what E&M code most appropriately reflects your assessment service. You would also need to indicate on the assessment that the case was canceled before induction, along with an explanation for the cancelation. If you are using an EMR (electronic record), this may be somewhat problematic as each EMR will have a different workflow—especially where a case is canceled before an anesthesia record is started. Accordingly, we encourage you to work with your group members and EMR IT staff to determine how to best notify the billing office about these pre-induction cancelations and how me might ultimately gain access to the pre-anesthesia assessment.

Incomplete Colonoscopies

While not technically a canceled case, the incomplete colonoscopy scenario is somewhat analogous. Since this scenario does occur from time to time, we will briefly address it here. An incomplete (often termed, "aborted") colonoscopy typically happens when the endoscopist is unable to place the scope to the fullest extent planned for the procedure. This is often due to an obstruction. In this eventuality, you can still get paid for the full base and time units; however, the surgical code (CPT) may change due to the limited procedure, which will further affect the modifier appended to the anesthesia (ASA) code.

What we need from you, from a documentation standpoint, is a description of the extent to which the scope was advanced before having to be pulled. There are three possible descriptions that we are looking for you to additionally list in the procedure field of the record that will help us more accurately code these types of abbreviated cases:

• Prior to splenic flexure
• To or beyond splenic flexure, but not to cecum
• To cecum

As long as we have one of these documentation components added to your colonoscopy procedure description, our coding team will have a greater chance of submitting a correct claim on your behalf when these unforeseen circumstances occur.