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Fall 2013

COMPLIANCE CORNER:  Time is of the Essence. Are We Double Dipping?

Darlene Helmer, CMA, CPC, ACS-AN, CMPE, MBA
Vice President of Provider Education & Training, ABC

CMS defines surgical anesthesia time as “the continuous, actual presence of a qualified anesthesia provider. This time begins when the anesthesia provider begins preparing the patient for anesthesia in the operating room or equivalent area. Anesthesia time ends when the anesthesia provider is no longer in personal attendance.” The ASA Relative Value Guide has a similar definition: “anesthesia time begins when the anesthesiologist begins to prepare the patient for anesthesia care in the operating room or in an equivalent area and ends when the patient is safely placed under post-anesthesia supervision.” This is a typical “clear as mud” definition when it comes to anesthesia and CMS. Exactly what is an equivalent area? Is this “equivalent area” ambiguity something we can use to our advantage or is it a disadvantage? Could it be both? It all depends on how or who does the interpretation of the anesthesia record; nevertheless, as long as it is documented properly and with medical necessity, the precise words can become unimportant.

Auditors have become more aggressive in the pursuit of improper payments. Recovery Audit Contractors (RAC) auditors are paid to find an issue, irrespective of its validity. It is hard to say what sparked this added target. One might speculate that a recent upsurge in the number of claims for the placement of post-operative pain blocks may be the contributing factor. These post-operative nerve blocks are usually separately billable, as long as the documentation supports that the placement was requested by the surgeon for post-operative pain Management. The question of double dipping may result, though. Specifically, when nerve blocks or invasive monitoring lines are placed before the start of a surgical case, the time spent performing these services should not be included in the reported anesthesia time. Hence a poorly documented record could result in what appears to be “double dipping.”

Typically, a surgical case and the anesthesia start time will correspond to the provider in-room time and end when the patient is safely turned over to a PACU or ICU nurse. When nerve blocks are performed for purposes of postoperative pain management or when invasive monitoring catheters are placed prior to induction, however, the time associated with these procedures should be deducted from the anesthesia time. Exceptions always exist. For instance, an unstable patient coming to surgery from an I.C.U. with lines in place may require the continuous attendance of an anesthesia provider during transport to manage the patient. This time should be included in the total time billed. A cardiac patient may need to have general anesthesia prior to the insertion of the lines. As with any rule, situations arise that require the use of the provider’s best judgment.

Documentation is the key to validate coding for the post-operative pain blocks and invasive monitoring lines. No “double dipping” for time is of the essence.

Darlene F. Helmer, CMA, CPC, ACS-AN, CMPE, MBA serves as Vice President of Provider Education and Training for ABC. She has 30+ years of healthcare financial management and business experience. Knowledgeable in billing, third-party reimbursement, coding and compliance issues, Ms. Helmer works to ensure the foremost information is presented at client in-services. She works closely with the compliance department and is a member of the ICD-10 training team. She is a long-standing member of MGMA, AHIMA, AAPC and other associations. She is a frequent speaker at local and state conferences. You can reach her at