Revenue Cycle Insider

Use this handy checklist to get your documentation ducks in a row.

Last month, we outlined the five steps Mary Garuccio, CANPC, CPMA, CPC, AAPC Fellow, ACS-AN, owner of Advanced Medical Practice Management LLC and senior consultant for RMA in North Carolina; and Dr. Laura McNeill, anesthesiologist at Allegheny General Hospital in Pittsburgh, recommended for flawlessly documenting your anesthesia services.

This month, we’ll examine more of the suggestions they made in their HEALTHCON 2024 presentation, “How to Succeed With Coding and Billing Anesthesia Services,” to help you refine your documentation for complex anesthesia and positioning. And we've added a helpful documentation checklist to aid you in compiling clean, comprehensive claims.

Know Anesthesia Types and Deliveries

McNeill noted that you must make sure you do not confuse the three types of anesthesia — general, regional, and monitored anesthesia care (MAC) — with the three different kinds of delivery methods — total intravenous anesthesia (TIVA), total inhalation anesthesia, and balanced anesthesia (a hybrid of intravenous [IV] medication and anesthesia gases). These distinctions are important to note accurately in the documentation, as general, regional, and MAC can all be delivered as TIVA.

Regional anesthesia can be neuraxial, which includes spinals or epidurals; IV regionals administered in the upper extremities; peripheral nerve blocks, which include suprascapular, femoral, and popliteal; and fascial plane blocks, which include erector spinae, TAP, and paravertebral.

MAC is always TIVA and can be anything from mild, or conscious, through to deep sedation. Here, the patient is always in control of their own ventilation, but a qualified doctor, certified registered nurse anesthetist (CRNA), or anesthesiologist assistant (AA) must be present in case the MAC does not work out and the service has to be converted general sedation.

Remember to Add These MAC modifiers

QS (Monitored anesthesia care service) is an informational modifier that indicates all MAC services other than the following:

• G8 (Monitored anesthesia care (mac) for deep complex, complicated, or markedly invasive surgical procedure), which is applied to MAC services accompanying complex or very invasive surgical procedures, such as transcatheter aortic valve replacements (TAVR); carotid endarterectomies (CEA); cerebral cavernous malformation (CCM) surgeries, such as craniotomies or laminectomies; or endovascular procedures
• G9 (Monitored anesthesia care for patient who has history of severe cardio-pulmonary condition), which is applied to MAC services for patients with a history of severe cardio-pulmonary conditions

And remember, only one MAC modifier should be reported per claim.

Note: IV conscious sedation is performed by a proceduralist, such as a dentist. This is not MAC, and it does not require an anesthesia professional to be present. The service is billed with 99151-+99153 (Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports …) and 99155-+99157 (Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports …).

Prepare to Pinpoint Patient Positioning

“This adds complexity and risk to anesthesia, which is why the AMA, the ASA [American Society of Anesthesiologists], and CMS [Centers for Medicare & Medicaid Services] all factor in field avoidance when they assign base units,” Garuccio reminded the audience. So, whenever the procedure requires the patient to be in a position other than supine (where the patient is horizontal facing upward) or lithotomy (the same, but with legs elevated), or the procedure requires field avoidance (procedures that do not allow the anesthesiologist to have access to the patient’s airway, such as procedures around the neck, head, or shoulders), remember to look for position documentation, which will allow you to not only use the correct code but also to claim full reimbursement.

Examples:

• Patient in supine position for an intracranial position: 00210 (Anesthesia for intracranial procedures; not otherwise specified) = 11 base units
• Patient in sitting position for an intracranial position: 00218 (Anesthesia for intracranial procedures; procedures in sitting position) = 13 base units
• Patient in supine position for a procedure on the cervical spine or cord: 00600 (Anesthesia for procedures on cervical spine and cord; not otherwise specified) = 10 base units
• Patient in sitting position for a procedure on the cervical spine or cord: 00604 (Anesthesia for procedures on cervical spine and cord; procedures with patient in the sitting position) = 13 base units

For anesthesia procedures less than 5 base units that require field avoidance: In cases where field avoidance is employed for procedures that do not normally call for it, “Increase your base units to 5, add modifier 22 [Increased procedural services], and add practitioner documentation to explain why there was field avoidance,” Garuccio advised.

Putting it All Together With Required Documentation Elements

To make sure your claims include everything needed for the payer to process fully and quickly, McNeill outlined all the documentation needed to report preoperative, intraoperative, postoperative, and postoperative visit anesthesia services. That advice is summarized in the following checklist:

Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC