# Where did I go wrong?



## jdibble (Dec 23, 2010)

If someone could help me understand this Anesthesia coding I would be greatful!  WE have just starting sending out our first round of Anesthisia claims so we are not too sure of what we are doing.  I had a patient who had an epidural for a vaginal delivery.  We billed Aetna and they are denying the claim (per the Aetna website) stating the following:

F2   Finalized/Denial-The claim/line has been denied.

Claim Status      Claim Status Description

     121              Service line number greater than maximum allowable for payer

The patient was given an epidural - start time was 11:15 and stop time was 13:45.  We billed code 01967-P1-AA 15 units (5 base units plus 10 units for time.)  The claim did include the times.  

Can someone please help?  We have sent out so many claims in the last few weeks and now I am worried that they are all wrong and this is only the beginning of the denials!! 

Thanks in advance for help!


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## cindyt (Dec 23, 2010)

There is no single method to bill time for neuraxial labor analgesia.  However, you must remember that when coding vaginal deliveries one time unit is equal to one hour of anesthesia care.


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## jdibble (Dec 23, 2010)

Thanks Cindy!  OK -well that is something I didn't know - I have been billing in the 15 minute increments!  So that may be why they are denying it as maximum allowable.  Is there a source that I can refer to that explains the time for vaginal deliveries?  Also, how would that be timed and billed then if the patient eventually was delivered by c-section? 

Thanks again for your help.


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## dwaldman (Dec 23, 2010)

http://asatest.asahq.org/Washington/aetnapolicies.pdf

Above is something that I found when looking for Aetna's anesthesia policy for deliveries. The hospital I work with, deliveries are not being performed (10 bed specility hospital) so I don't know coding for your question. But the only thing that I was questioning is the fact that you said you added the base units to the time. To me this is for the payment equation for carriers, my understanding and the way I bill is total minutes in box 24g (units box). I also list start and end times in the box 19 or electronic corresponding section. Then the carrier takes  the total minutes plus the base units x conversion factor and  any modifying factors. But again I only consider the base units for the carrier's  payment equation not to add to the minutes. Describe in this link 
http://www.cms.gov/manuals/downloads/clm104c12.pdf
on page 119 stating that the total number of minutes should be reported, but never do they indicate you should add the base units to this number.

Below is an Q & A from Supercoder that I found when looking at delivery coding. You were asking about more information. I have had their Anesthesia Specility Alert thru The Coding Institute which is within the Supercoder  and a lot of their articles are on anesthesia coding. Another one is Decision Health's Anesthesia/Pain program:
http://www.anesthesia-decisions.com/ You can call them and they will give a free trial, when I did the trial there was some great ansthesia articles. I would recommend both programs for articles they write on coding. 


Question: Can you give me a specific example of when the new obstetrical anesthesia code 01960 (Anesthesia for; vaginal delivery only) would be used? We have never billed a vaginal delivery only without any type of anesthesia; we generally use 01967 (Neuraxial labor analgesia/anesthesia for planned vaginal delivery [this includes any repeat subarachnoid needle placement and drug injection and/or any necessary replacement of an epidural catheter during labor]).

Florida Subscriber

Answer: Any CPT code beginning with “0″ designates that anesthesia was provided for a procedure. Therefore, code 01960 means the anesthesia professional provided anesthesia for a procedure that only involved a vaginal delivery (in other words, it didn't lead to any other procedures afterward). It is similar to code 01967, but 01967 requires that the anesthesia provided be neuraxial.

Patients can have other types of anesthesia for complications during a vaginal delivery; in that case general anesthesia or MAC may be given, and code 01960 would be reported. Likewise, 01961 means that anesthesia was supplied during a cesarean section with no other procedures before or after it; the patient had a c-section during that operative period and nothing else. 

__________________________________________________________________

 "There is no single method to bill time for neuraxial labor analgesia. However, you must remember that when coding vaginal deliveries one time unit is equal to one hour of anesthesia care."
Today 12:19 PM 

In Response, 
Cindy, I am not familiar with delivery anesthesia coding, but when I was looking at the codes I was trying to understand where it is mentioned that "one time unit is equal to one hour of anesthesia care"? I was  just trying to understand how these codes are different the typical report the total minutes and payment methodology of 15 minutes  equaling the payer's concept of 1 unit.


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## cindyt (Dec 27, 2010)

If you refer to the relative value guide on page 22 it describes a little about obstetric anesthesia.  The reason why the billing is different between a 01967 and a regular procedure is that in most cases the anesthesiologist is not present during the entire delivery.  The anesthesiologist is present during the insertion of the epidural catheter and then he/she leaves the room.  The epidural then runs on it's own until the baby is delivered.  After the baby is delivered the anesthesiologist then returns to the room at some point to remove the catheter.   The only face to face time the anesthesiologist has with the patient (once again in most cases) is the insertion and removal of the catheter.  Therefore, we can not bill a 01967 with the entire total minutes of care. 

Jodi-To help you with your patient-Am I correct to assume that your anesthesiologist was not in the room with the patient the entire time she was in labor?  Do your anesthesiologist's break out time for the epidural insertion, infusion time and removal of catheter?  At our office we ask for 4 times to be documented.  The start and stop time for the epidural insertion, and the start and stop time for the continuous infusion.  If they can they are also asked to provide the start and stop time for the epidural removal.


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## jdibble (Dec 28, 2010)

Cindy - Yes, I assume the anesthesiologists was not in the room due to the length of time, but he only lists his start time and stop time in total.  He does not break down any other times for the epidural.  I have two I am currently coding where he has start 1645-2315 (6hrs 30 mins) and 0632-1736 (11 hours).  I don't have the RVG book, but according to the ASA Crosswalk I use, to bill the epidural you would consider base unit of 5 + time. How would you code the time for these cases then?

Dwaldman - thanks for the links - I will check them out to see if they help. As far as adding total time and base units, that was how it was explained to me to bill. The issue I have is I have to code the cases and then it gets passed on to a charge entry person who enters it into the system for claim processing - I have no idea what goes in what box or how to break it down.  I give the charge entry person the total amount of units (base unit and time) any units for P modifiers and the start and stop times.  She enters it into the system which goes to the billing company for submission.  I never see the claim so I have no idea how it looks or presents electronically to the carriers.  I just need to know exactly how to code it so that charge entry has the correct information to enter.

I appreciate all of your help - this anesthesia thing is making me feel more clueless everyday!


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## dwaldman (Dec 28, 2010)

Jodi, 

I would not add the base units. You need to provide only the total minutes. If other forum members disagree with this suggestion, please relay that concern. But my personal experience is you do not add base units to the time.


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## jdibble (Dec 28, 2010)

dwaldman - please see this link on the discussion board -
https://www.aapc.com/memberarea/forums/showthread.php?t=43685

this is how it was explained to me on how to code anesthesia, and that is how I have been coding them for the last two months!  I also attended a webinar which basically stated the same thing... so I am confused as to how you are saying I should be coding my units for anesthisia?

Thanks,


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## gost (Dec 28, 2010)

Hi again Jodi.

In the thread you refer to, I may have been a bit simplistic.  While the info I gave you is accurate (I hope) for calculating your fee, it may not always be correct for what goes on your claim form.  Some (maybe most) payers want time units only and they add in the base units.  So if you have a procedure with 3 base units and 4 time units, you bill for 7 units but only put 4 units on the claim form.  (So if you bill $100/unit, you will bill for $700 but in the units field you will only report 4).  

A word of caution:  not all carriers want anesthesia reported the same way.  I think most want billed like DWaldman says but there are (or at least were as recently as last spring) some who want base and time units and some that want base units and want start and stop time repiorted ao they can add in the time (I used to work for one that did that).

In addition, some payers place a cap on time units for deliveries (I don't know about Aetna).  The best thing to do is find out the billing guidelines for all the major carriers you will be billing.  It's a bit of work up front that will save a lot of work later.

Sorry if I caused you any confusion.  Sorry if this causes even more.    Hang in there.   It gets easier.


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## dwaldman (Dec 28, 2010)

From the Relative Value Guide

III. Time Units

Time units will be added to the base unit value and modifying units as is customary in the local area.

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 anesthesiologist is no longer in personal attendance, that is, when the patient is safely placed under post-anesthesia supervision.

IV. Obstetric Anesthesia:

Unlike operative anesthesia services, there is no single, widely accepted method of accounting for time for neuroaxial labor analagesia.

Professional charges and payment policies should reasonably reflect the costs of providing labor analgesia as well as the intensity and time involved in performing and monitoring any neuraxial labor analgesic.

Metods to determine professional charges consistent with these principles include:

-Base units plus time units (insertion through delivery), subject to a reasonable cap.

-Base units plus one unit per hour for neuraxial analgesia management plus direct patient contact time (insertion, management of adverse events, delivery, removal).

-Incremental time-based fees (e.g., 0<2 hurs, 2-6 hrs, >6 hrs).

-single fee

________________________________________

From my previous response
http://www.cms.gov/manuals/downloads/clm104c12.pdf
on page 119 stating that the total number of minutes should be reported, but never do they indicate you should add the base units to this number.

As I said in my previous response,  if you check the Medicare Claims processing manual Chapter 12, they indicate to list the number of total minutes in the units field or written out if someone else doing the charge entry. I personally bill all carriers this way and don't report physical status modifiers or codes such as 99100-99140. I agree with Gost that there are carrier's out there that might want it different, but due to the fact that I am not seeing a lot compliants from the patient account reps at the office, I am billing based on the guidance in Medicare Claims processing manual across the board for all carriers. After the suggestion of Cindyt that I should  look  at the ASA Relative Value Guide , now it  does make a lot more sense on Obstetric anesthesia and understand her previous post better. Jdibble, forgive me if I took your the response to your question on a tangent due my lack of understanding in certain areas, but I am thankful for Gost and Cindyt  to clear any confusion and I will be not so quick to respond on some of these anesthesia questions in the future as they can be more complex than what they first appear.


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## jdibble (Dec 29, 2010)

Gost and Dwaldman - again thanks for your assistance with this!! I  hope I am not wearing out my welcome with all of this!

Yes - I am getting quite confused , but I am working on figuring this thing out!  I have checked out all of the links that dwaldman gave me, which was very helpful.  I have also found alot of information on other sites and see that there is really no cut and dry answer to these issues! 

Gost - from your other post - you were very helpful in explaining how to come up with the charge.  I think I misunderstood that this was also how it would be applied to the claim. However, I also did a Webinar which basically explained the same thing about totaling base units and time units and even explained for Medicare that we needed to round to the nearest 10th - but never stated not to include the base units or modifing units when entering it on the claim. Nor did they specifiy that you would actually enter the total time in minutes in the unit box rather than the time in units.  Now I am finding information out there on the internet that tells me never to include the base units when we bill! I will take your word for it that this will get easier! 

Dwaldman - As far as Medicare - I had read that chapter in the Medicare guidelines in the beginning when I had started this adventure, but apparently I misunderstood what they were requesting (along with the help of a misleading Webinar).  Let me see if I understand this correctly - in the box for units, rather than entering the time in units (2 hours = 8 units) I would enter 120?  It appears that this is also what BCBS is requesting - time in minutes?  At one point I read that I need to enter the actual start-stop time in box 19 - is that needed?  And you say you bill all of your claims this way? That would be much easier if it works! 

The only thing I would still have to figure out is this epidural thing - I did read the information Dwaldman just posted somewhere else, which of course again is not cut and dry!  I will keep searching on that one!

Thanks again to all for helping me to try and understand this - out of all the coding that I have done, I have never felt so confused on how to bill something out!


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