Documenting Anesthesia Services

Kelly D. Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I
Perfect Office Solutions, Inc., Leesburg, FL

I’m often asked what kind of documentation is necessary to support anesthesia services. Answers will vary, based on the anesthesia practices’ unique characteristics. For example, an anesthesia practice that uses a “care team” approach—employing medically directing anesthesiologists and Certified Registered Nurse Anesthetists (CRNAs) and Anesthesia Assistants (AAs)—will have different requirements than a practice where anesthesiologists personally perform all procedures. Additionally, documentation requirements in a teaching facility are more comprehensive than those in a private anesthesia practice.

Let’s start with basic documentation requirements, and move to alternative examples as we go.

Basic Documentation Requirements

The National Committee for Quality Assurance (NCQA) publishes 21 elements in its Guidelines for Medical Record Documentation, with six listed as core components; however, not all of the requirements pertain to anesthesia providers (who do not usually have a patient relationship beyond and unrelated to anesthesia services provided for surgical procedures). From this list, basic documentation principals applicable to anesthesia services are as follows:

• Each page in the record contains the patient’s name or identification (ID) number;
• All entries in the medical record contain the authors ID. Author ID may be a handwritten signature, unique electronic ID or initials; (Note: If anesthesia practices are still using paper records, a staff log is recommended for all signatures and initials)
• The record is legible to someone other than the writer.

The American Association of Nurse Anesthetists (AANA) publishes comprehensive documentation guidelines on its website. The American Society of Anesthesiologists (ASA) does not publish documentation guidelines, although guidelines for Basic Standards for Pre-Anesthesia Care, Basic Anesthesia Monitoring, and Post-Anesthesia Care are available to both members and non-members. Solo CRNA practices may choose to follow AANA guidelines, as referenced in the resources. The information provided in this article is based on ASA information.

Pre-Anesthesia Care

In accordance with the ASA Guidelines, “An anesthesiologist shall be responsible for determining the medical status of the patient and developing a plan of anesthesia care.” The Center for Medicare & Medicaid Services (CMS) requires that a medically directing anesthesiologist sign the pre-anesthesia documentation. All of the following guidelines pertain to pre-anesthesia care, with the exception of documented medical emergencies:

• Reviewing the available medical record;
• Interviewing and performing a focused examination of the patient to:
  • Discuss medical history, including previous anesthetic experiences and medical therapy;
  • Assess those aspects of the patient’s physical condition that might affect decisions regarding perioperative risk and management;
  • Order and review pertinent available tests and consultations as necessary for the delivery of anesthesia care;
  • Order appropriate preoperative medications;
  • Ensure that consent has been obtained for the anesthesia care; AND
  • Documenting in the chart that the above has been performed.

Intra-Operative Anesthesia Care

The ASA developed Standards for Basic Anesthesia Monitoring in 1986, which were last updated October 28, 2015. Although emergency circumstances and life-saving measures take precedence, the following broad standards apply, with defined methods:

• Standard I – Qualified anesthesia personnel shall be present in the room throughout the conduct of all general and regional anesthetics and monitored anesthesia care (MAC).
• Standard II – During all anesthetics, the patient’s oxygenation, ventilation, circulation and temperature shall be continually evaluated.

Post-Operative Anesthesia Care

Standards for Post Anesthesia Care were last updated by the ASA on October 15, 2014. They apply to General, Regional or MAC provided at any location. The standards require all patients, unless specifically ordered otherwise by the anesthesia provider, to be admitted to a Post Anesthesia Care Unit (PACU) or equivalent area. The anesthesia provider is responsible for the patient, including support appropriate to the patient’s condition, until patient care is transferred to a PACU nurse.

Reviewing Documentation

Anesthesia record auditors check anesthesia graphs, available on both paper and electronic records, to ensure continuous monitoring by the anesthesia provider, and can confirm the reported anesthesia time several ways.

One method is to review both the documented time along the top of the anesthesia graph and counts the “tick” or monitoring checks as a five-minute increment, based on ASA’s guidelines of monitoring and evaluating the patient’s arterial blood pressure and heart rate at least every five minutes. These monitoring checks should begin shortly after the reported anesthesia start time, and end in proximity to the reported anesthesia stop time, unless documentation supports a delay or complication. Another method compares reported anesthesia times to the operating room (OR) circulator and PACU notes. Although these times typically will not match exactly, they should be close to the reported anesthesia times. Time checks are the same for any type of anesthesia practice.

Documentation in the medical record should support specific anesthesia modifiers reported. Anesthesia modifiers were listed on the Office of Inspector General (OIG) Work Plan under “Anesthesia Services – Payments for Personally Performed Services” from 2013 through 2018. Although the report number was removed from the Work Plan last year, it is still important to have an understanding of what each of the modifiers mean in relation to the documentation.

Medical direction modifiers (See Table 1) indicate to CMS and other insurers that certain steps have been followed by a medically directing anesthesiologist, as defined in the Medicare Claims Processing Manual (MCPM), under Chapter 12, Section 50, Payment for Anesthesiology Services. Anesthesia practices using the care team approach and reporting medical modifiers “QY” or “QK” and “QX” will look for documentation to support the reported modifiers. According to CMS, “Medical direction occurs if the physician medically directs qualified individuals in two, three or four concurrent cases and the physician performs the following activities.” These are also known as the “seven steps” of medical direction.

1. Performs a pre-anesthetic examination and evaluation;
2. Prescribes the anesthesia plan;
3. Personally participates in the most demanding procedures in the anesthesia plan, including induction and emergence;
4. Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist;
5. Monitors the course of anesthesia administration at frequent intervals;
6. Remains physically present and available for immediate diagnosis and treatment of emergencies; and
7. Provides indicated-post-anesthesia care.

CMS allows six exceptions in the online manual that some carriers consider to be illustrative, rather than exhaustive, such as:

1. Addressing an emergency of short duration in the immediate area;
2. Administering an epidural or caudal anesthetic to ease labor pain;
3. Periodic, rather than continuous, monitoring of an obstetrical patient;
4. Receiving patients entering the operating suite for the next surgery;
5. Checking or discharging patients in the recovery room; and
6. Handling scheduling matters.

“Frequently Asked Questions (FAQs)” were on several Medicare Administrative Contractor websites that indicated:

“As long as the medically directing anesthesiologist ‘remains physically present and available for immediate diagnosis and treatment of emergencies’ (rule number “vi” of the CMS “seven requirements”), we agree that the following procedures would be an illustrative but not exclusive list of allowed interventions:

• Placement of a Swan-Ganz catheter, central line or arterial line
• Placement of an epidural catheter for post-operative analgesia or in preparation for subsequent surgery (for a ‘to follow case’)
• Placement of other peripheral nerve blocks prior to subsequent surgery, to include brachial plexus blocks, ankle blocks, femoral nerve blocks, etc.”

However, one is hard pressed to find these answers online now, as many of the FAQs have disappeared over the years. Novitas has published, removed and published again a variation of FAQs, which currently indicates as follows:

“An anesthesiologist may perform and, if otherwise eligible, seek reimbursement for procedures (such as arterial line insertions, central venous catheter insertions, pulmonary artery catheter insertions, and epidural, spinal, and peripheral nerve blocks) performed in an area immediately available to the operating room when performance of such services does not prevent him/her from being immediately available to respond to the needs of surgical patients.”

This information was last modified July 15, 2019. When you find this kind of information published, keep a copy on your hard drive or print it out to include with your compliance information. As mentioned, when these are no longer available you will have support for following the guidelines.

Any anesthesia practice working with “qualified individuals,” including residents, fellows, CRNAs, AAs and Student Registered Nurse Anesthetists (SRNAs), should be aware of CMS’s medical direction requirements and exceptions. Many private payer policies have also adopted these guidelines.

Anesthesia practices involved in teaching have additional rules to follow. Information regarding teaching documentation requirements is available in the MCPM under Section 100, Teaching Physician Services. A teaching physician is defined as “A physician (other than another resident) who involves residents in the care of his or her patients.” Anesthesia services furnished in teaching settings are paid under the physician fee schedule if the services are:

• Personally furnished by a physician who is not a resident;
• Furnished by a resident where a teaching physician was physically present during the critical or key portions of the service.

If an “AA” modifier or “AA GC” modifiers are reported, documentation must support either personal performance or documented teaching of one or two residents. In my personal experience, electronic anesthesia records (EARs) are helping to improve teaching documentation as EARs clearly identify who was in the room, who provided which service, and typically include legible attestations from the teaching anesthesiologist.

If more than one teaching anesthesiologist worked with the resident, Medicare requires the claim to be filed under the teaching anesthesiologist who started the case, with the GC modifier appended to indicate which services were performed by the resident. CMS does not require a GC modifier for SRNA services because the modifier description pertains only to residents or fellows, depending on the circumstances.

CMS allows a teaching CRNA to report full base and anesthesia time (QZ modifier), under the teaching CRNAs provider number, for two concurrent cases, provided that the teaching CRNA is not medically directed by an anesthesiologist, and the CRNA is present with the SRNA during the pre- and post-anesthesia care for each case. The CRNA must document her or his involvement with each of the two cases.

Conversely, CMS allows a teaching anesthesiologist to report either personal performance (AA modifier) if she or he is continuously involved in a single case with an SRNA or medical direction (QK modifiers) for two concurrent cases, provided that the steps for medical direction have been followed. In effect, a teaching CRNA may receive full payment for teaching two SRNAs, whereas a teaching anesthesiologist only receives partial payment for their medical direction. No payment is made under Part B for services provided by a SRNA. This is important to keep in mind if a SRNA solely places an arterial line, for example, without the teaching CRNA or anesthesiologist’s involvement.

Depending on your compliance plan or policy, anesthesia practices conduct either internal or external reviews (or a combination of both) to spot-check documentation, as compared to the information sent to CMS or other insurance companies. There are additional areas of documentation concern, some general and some specific to anesthesia. The medical record should support all information provided on an anesthesia claim form, with examples indicated below:

• Provider of medical service or services.
• Diagnosis and procedure codes.
• Anesthesia times, including documented discontinuous anesthesia time and any case relief or transfer of patient care—this is particularly important if your state Medicaid reporting labor epidural services.
• General, Regional or Monitored Anesthesia (MAC): CMS and other insurance companies may have medical necessity policy and/or require a QS, G8 or G9 modifier when MAC is provided.
• Indication of physician or teaching CRNA presence at induction, emergence and other “demanding” procedures: note that induction and emergence are not applicable to regional or MAC, although documentation of presence during initiation or placement may apply.
• Procedure notes for invasive monitoring lines and/or other “surgical” procedures, including who provided the service and when time notations allow coders to determine when blocks or catheters are placed and whether discontinuous time is applicable. Keep in mind that these “surgical” procedures (such as an arterial line) are not “medically directed or supervised”, which only pertains to anesthesia services.
• Surgeon’s request for post-operative pain management, when applicable.
• Qualifying circumstances, such as an emergency*.
• Physical status, such as a patient with a severe systemic disease*.

*Although CMS does not allow the reporting of physical status modifiers or qualifying circumstances procedure codes, other insurances may recognize and pay for these difficult anesthesia situations.

Documentation compliance is more than just an expectation—it is a necessity. Regardless of whether your anesthesia practice has a formal compliance plan, under the Federal Register Publication of the OIG Compliance Program Guidance for Third-Party Medical Billing Companies, the OIG believes that all healthcare providers should be using internal controls to “more efficiently monitor adherence to applicable statutes, regulations and program requirements.” It is vital providers of anesthesia services understand what information is billed on their behalf and whether they conform to these readily available guidelines.

Resources

American Association of Nurse Anesthetists (AANA), Documenting Anesthesia Care, © Copyright 2016 https://oig.hhs.gov/fraud/docs/complianceguidance/thirdparty.pdf

American Society of Anesthesiologists (ASA), Standards and Guidelines https://www.asahq.org/standards-and-guidelines

Center for Medicare and Medicaid Services, Medicare Claims Processing Manual, Chapter 12 – Physicians/Non-Physician Practitioners https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf

National Committee for Quality Assurance (NCQA), Guidelines for Medical Record Documentation http://www.ncqa.org/portals/0/policyupdates/supplemental/guidelines_medical_record_review.pdf

Office of Inspector General, Work Plan https://oig.hhs.gov/reports-and-publications/workplan/index.asp

Novitas Solutions (July, 2015) Anesthesia https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00173915

Office of Inspector General, Compliance Guidance, Federal Register / Vol. 63, No. 243 / Friday, December 18, 1998 / Notices https://oig.hhs.gov/fraud/docs/complianceguidance/thirdparty.pdf

Kelly D. Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I, has over 36 years of experience in anesthesia coding and billing and speaks about anesthesia issues nationally. She has a Masters Degree in Business Administration, is a certified coder and instructor through the American Academy of Professional Coders. Kelly is an Advanced Coding Specialist through the Board of Medical Specialty Coding and served as lead advisor for their anesthesia board. She is also a certified healthcare auditor and has owned her own consulting company, Perfect Office Solutions, Inc., since November 2001. She can be reached at kellyddennis@attglobal.net.