The Pros and Cons of Automated Anesthesia Records

Vendors of automated anesthesia record systems would have you believe they are practically god's gift to the specialty of anesthesia. They will capture more information about each anesthetic more conveniently and report it back more legibly than paper records ever could. They will also enhance the completeness and accuracy of billing by ensuring that all critical elements necessary to complete a claim are communicated to the billing office. It often sounds too good to be true, which is often the case. Implementing an automated anesthesia record system is not without its challenges and shortcomings.

There is no doubt that a provider who completes a paper anesthesia record has a fair degree of editorial authority to create a record that indicates appropriate care and a positive outcome. There is always the question, however, as to what extent the manual record reflects what occurred during the course of the case. Providers tend to document key clinical indicators after the fact and as they remember them. To the consternation of some anesthesia providers, automated record systems capture data trails directly from the monitors. Editing of invalid or inappropriate readings is possible but can be cumbersome.

The Training Challenge

It has been fascinating to monitor the implementation of automated record systems across the country. Providers tend to fall into two categories: the senior physicians who can be somewhat resistant to the new technology and less willing to embrace a new system and the more recent graduates who are eager to make the most of the new technology and its potential. All these systems have what are referred to as soft and hard stops that are intended to ensure that all necessary information is captured. While these edit tools are intended to ensure that every record is complete and accurate, this is not always the case. Since every case is unique it is impossible to anticipate every specific requirement with system edits.

Training providers to complete automated records correctly may require a significant commitment on the part of the anesthesia department. This is especially important when the system sold to the practice has had to be modified or amended to meet the specific requirements of the department. Rare is the system that is implemented without extensive and expensive program modifications. Incidentally, this is often a significant source of income to the software vendor. One of the main advantages of such systems is that providers can create templates for the most common types of cases they perform. These can be real time-savers but require careful attention to the details in their creation. Serious users often create an extensive set of templates for their favorite cases.

While Epic and Cerner are the largest providers of electronic medical records systems, especially to academic centers because they are typically enterprise-wide solutions, the specific requirements of an anesthesia department are sometimes of lower priority. Many academic centers using Epic have had to make a substantial investment for system modifications. Some have even had to develop a separate system to best utilize the potential value of the database. This is especially true when the intent is to mine the clinical data captured.

From A Billing Perspective

One of the key issues with any automated record system is where the data comes from and who enters it. Typically, the procedure and diagnosis are captured during the scheduling process. O.R. staff may assume responsibility for updating the diagnosis. This can be problematic since anesthesia claim preparation should be based on the most complete post-operative procedure and diagnosis. One limitation affects many systems, the actual providers have limited ability to edit procedure and diagnosis details. This often makes it necessary for the anesthesia coders to pull a copy of the operative report to confirm their coding. Because of this, communication among the various stakeholders is critical. The O.R. staff needs to have a clear understanding of what details are critical to appropriate anesthesia billing. The good news is that it is the anesthesia provider alone who determines start and end times.

The following are some of the common challenges encountered by our coders when reviewing automated records.

Diagnosis:

• Missing diagnosis description: pre and post
• Incomplete diagnosis description: abbreviations, lacking specificity
• Diagnosis variations from op report documentation

Procedure:

• Missing procedure description
• Incomplete procedure description
• Lacking required documentation for anesthesia in procedure description: site, upper/lower abdomen, extensive spine procedures etc.

Out of O.R. procedures often pose a special challenge because they may not be included on an anesthesia record. Separate services such as blood patches, emergency intubations on the floor and consults may have to be captured separately. One common challenge for cardiovascular anesthesia care is confirmation of the details of TEE performed and whether it meets the requirements of a higher level of code (93312).

It is also not uncommon, especially for practices that cover multiple sites, that the automated record is not available for all anesthetizing locations. This entails some special requirements to ensure the completeness and accuracy of the paper records from these outlier sites. Often these are endoscopy sites, in which case capturing both the pre-op and post-op diagnosis can be problematic.

The Interface Challenge

Anesthesia billing is completely different from that of all other medical specialties that are CPT code and fee schedule based. While a significant percentage of radiology billing, for example, can be completed based on a clinical data download, this is not possible in anesthesia. Effective and appropriate anesthesia billing requires certified coders to review the entire record to ensure that all possible billing opportunities are captured.

Many providers scratch their head in frustration when they hear this, but the fact is that over the years we have learned that it is simply more efficient and effective to have qualified coders review each record to identify any billable elements. Compliant anesthesia billing involves the application of various algorithms. Nerve blocks, for example, are only separately billable when the block is not the primary mode of anesthesia. The blocks themselves can only be billed if the requisite documentation requirements have been met. Another example pertains to invasive monitoring: the CVP is only separately billable if it is indicated as a separate stick and not the introducer for the Swan Ganz catheter.

Although it is true that records prepared by an electronic record are more complete and legible than paper records and that they typically eliminate the need for separate charge tickets, they do not completely eliminate the need for provider returns: i.e., sending records back to providers for clarification, especially for concurrency issues.

The Ultimate Challenge and Opportunity of Automated Records

Most departments are primarily interested in optimizing collections for the valuable services they provide, and this often determines their priorities when it comes to their records. This is somewhat short-sighted since the greatest challenge facing the average practice today is managing the cost of providing the care in the face of downward revenue trends and scope creep with regard to hospital coverage requirements. Anesthesia departments have more and better data about what actually happens in the O.R. suites and the delivery rooms. This should represent a huge opportunity to influence critical decision-making on the part of the administration and the O.R. staff. Unfortunately, the full potential of this data has yet to be realized in many practices. If you have any questions, please contact your account executive or reach out to us at info@anesthesiallc.com.