Fall 2021
Both New and Seasoned Coders Should Know the Many Risk Areas in Anesthesia Coding
Kelly Dennis, MBA, ACS-AN, CANPC, CHCA, CPMA, CPC, CPC-I
Perfect Office Solutions, Inc., Leesburg, FL
The American Medical Association’s (AMA’s) 2021 CPT® codebook will likely be released without specific anesthesia-related code changes for the coming year, although coders will need to be aware that 2023 may bring substantial changes to the way postoperative pain management is reported. As there are no anesthesia-specific coding changes to consider for 2022, it is always a suitable time to review anesthesia coding basics and frequent coding problem areas.
Anesthesia services represent a small portion of CPT, but correct anesthesia coding requires complete comprehension of various anesthesia guidelines. Services reported by anesthesia providers are not limited to anesthesia codes 00100-01999; and instructions found in the CPT Anesthesia Guidelines do not cover many of the coding nuances specific to anesthesia billing [for instance, coding for the services of a Certified Registered Nurse Anesthetist (CRNA) or an Anesthesia Assistant (AA), which may also be referred to as a Certified Anesthesia Assistant (CAAs)]. Additional coding resources are required to gain a better understanding of anesthesia coding.
CMS and NCCI Offer Anesthesia Resources
The Centers for Medicare & Medicaid Services (CMS) and the National Correct Coding Initiative (NCCI) each publish information regarding anesthesia coding regulations. Although not all insurance companies follow CMS and/or NCCI guidelines, many use interpretations of both guidelines. Both publications are available through the Anesthesiologist Center of the CMS website, resourced at the end of this article.
The CMS Internet-Only Manual (IOM) provides guidelines for both anesthesiologists (Section 50 – Payment for Anesthesiology Services) and CRNAs (Section 140 – CRNA Services). Although CAAs are not specifically mentioned in the chapter heading under CRNA, the guidelines were revised more than 19 years ago (in 2002) to include anesthesia assistants. CMS recognizes both CRNAs and CAAs as non-physician practitioners (NPPs) and other insurances or resources may recognize these providers as a Qualified Health Professional (QHP). Commercial insurances typically do not make a distinction between the two anesthetist types with regard to payment for services provided under medical direction of an anesthesiologist. Coders may also find that insurances do not separately recognize these types of anesthesia clinical staff. It is enough to keep practices on their toes!
Although many practices are familiar with the care team approach which includes anesthesiologists and CRNAs, fewer may be familiar with CAAs. As of June 2019, CAAs are licensed in fourteen states with delegatory authority in two additional states and also are recognized under the TRICARE system. One important distinction between CRNAs and CAAs (depending on state scope of practice, delineation of privileges by the facility and individual malpractice carrier requirements), is that CRNAs may be allowed to practice as nonmedically directed, whereas a CAA must be medically directed.
The most up-to-date version of the NCCI (as of this writing) is 27.2, which became effective July 1, 2021. Anesthesia guidelines are found in Chapter Two. These guidelines for anesthesia coding are much more in-depth than CPT guidelines and include an introduction to correct coding for anesthesia and information regarding which services are bundled. For example, time spent during the usual pre- and post-operative visits, patient monitoring and various other activities are bundled into the base value of anesthesia services.
NCCI also discusses which services are billable separately. Separate procedure services, such as insertion of an arterial line [36620 Arterial catheterization or cannulation for sampling, monitoring or transfusion (separate procedure); percutaneous], Swan-Ganz catheter [93503 Insertion and placement of flow directed catheter (e.g., Swan-Ganz) for monitoring purposes], and a central venous pressure line (36555 Insertion of non-tunneled centrally inserted central venous catheter; younger than 5 years of age and 36556 Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older) are payable separately to anesthesiologists, as well as to CRNAs/ CAAs if these procedures are furnished within the parameters of state licensing laws. The NCCI also provides examples of coding scenarios regarding postoperative pain management, ventilation management, and discontinuous time. The postoperative pain management example explains factors to help coders determine when postop pain is considered outside of the global surgical package. According to the CPT Editorial Summary of Panel Actions, May 2021, coders should expect “Accepted revision of codes 64415, 64416, 64417, 64445, 64446, 66447, and 64448 to include ultrasound guidance, when performed” to become effective in January 2023.
Armed with the knowledge gleaned from these published anesthesia resources, you can gain valuable insight into information available to insurance companies. Keep in mind, however, that it is up to individual payers to determine which guidelines to follow. For example, many payers follow guidelines set forth in the American Society of Anesthesiologists (ASA) Relative Value Guide® (RVG).
Be Watchful of Payer-Specific Guidelines
Anesthesia coders should understand that anesthesia coding and billing guidelines will change from state to state and from payer to payer. Although CMS loosely follows the same IOM guidelines across all states, each Medicare administrative contractor (MAC) has its own idiosyncratic payer rules. This also is true for Medicaid, Blue Cross/Blue Shield (BCBS) and worker’s compensation. Individual payer contracts often include verbiage indicating their specific billing policies should be followed, yet they may or may not provide a copy of their coding/ billing policy. The best rule of thumb when there is not a policy is to follow the ASA RVG guidelines and use this resource in the event an appeal is necessary.
One of the best ways to ensure your practice is following individual state- and payer-specific anesthesia guidelines is to research which guidelines are available from your practice’s payers. The internet has made it easy to access information, although other sites may require provider login information (e.g., Blue Shield of California). If the information is not provided or accessible, it should be requested and reviewed on an annual basis, at a minimum. The onus for keeping up to date with changing regulations is placed solely on the anesthesia provider— who, in turn, typically relies on his or her coding and billing staff to know when changes occur.
Communicate Potential Risk Areas wit h Clinical Staff
Risk areas for anesthesia providers usually are understood by the coding and billing staff yet are not always relayed to the clinical staff. Coders understand the doctrine, “If it wasn’t documented, it didn’t happen.” With anesthesia records, however, sometimes it is very difficult to determine the exact diagnosis and procedure code and/or who actually provided services.
For example, if the anesthesia record has a check box for placement of an arterial or central venous pressure (CVP) line, and both an anesthesiologist and CRNA or CAA are involved in the case, a check mark doesn’t indicate clearly who placed the arterial line or CVP. Because some carriers may require services to be filed under the name of the provider who performed the service, the service may go unbilled unless clear procedure notes are documented either in the Remarks or Comments section or provided on a separate procedure form.
Another risk area is medical direction criteria. Many anesthesiologists fail to sign or initial their participation appropriately with a teaching or a medically directed case and may consider their signature as sufficient documentation of involvement. CMS and other payers require documentation during the most demanding procedures in the anesthesia plan, which includes induction and emergence, when applicable. Unless a monitored anesthesia care (MAC) case converts to general, induction and emergence are not applicable in such cases. Similarly, there is not an induction or emergence period associated with regional anesthesia.
Time Really Can Be Relative
Time reporting on claims may vary, and there is no national guidance that may be applied to all payers. According to the CPT Anesthesia Guidelines, time units are reported as is “customary in the local area.” Although Medicare requires exact time reporting, other payers may request either rounded time, or time in units, rather than minutes. Anesthesia providers always should provide exact start and stop times on the anesthesia record that, according to the ASA, correlate with their definition, last updated in 2019, as follows:
“Anesthesia time is defined as the period during which an anesthesia practitioner is present with the patient. It starts when the anesthesia practitioner begins to prepare the patient for anesthesia services in the operating room or an equivalent area and ends when the anesthesia practitioner is no longer furnishing anesthesia services to the patient, that is, when the patient is safely placed under postoperative care. Anesthesia time is a continuous time period from the start of anesthesia to the end of an anesthesia service. In counting anesthesia time for services furnished, the anesthesia practitioner can add blocks of time around an interruption in anesthesia time as long as the anesthesia practitioner is furnishing continuous anesthesia care within the time periods around the interruption.”
Coders should not expect to see large or unexplained gaps of anesthesia time around either the start or stop times, or times that routinely end with a “0” or “5.” Internal reviews of anesthesia times should be performed periodically to ensure your practice is checking this compliance risk area at a minimum! Because there are so many risk areas in anesthesia coding, it is necessary to understand the importance of following payer guidelines and keeping up to date with changes regularly.
If you see risk areas in your practice, work closely with your anesthesia clinical staff to ensure correct coding, documentation and billing. Keep in mind that although there may not be expected anesthesia specific code changes this year, the RVG may contain changes to either parenthetical notes or other information. Make sure you check the Summary of Changes found at the beginning of the book when you receive your 2022 RVG.
Resources:
https://www.ama-assn.org/about/cpt-editorial-panel/summary-panel-actions
https://www.cms.gov/Center/Provider-Type/Anesthesiologists-Center?redirect=/center/anesth.asp
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf
https://aaaa.memberclicks.net/assets/AAAA%20Work%20States%20Map%20June%202019.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 and 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.
