Anesthesia Coding Alert

Complete documentation for anesthesia relies on 10 basic must haves including correct use of modifiers, detailed reports, reasons for cancellation and start and stop times.

The more information the anesthesia record includes, the better, as far as insurance carriers are concerned. Robin Fuqua, CPIC, a certified insurance coder with Anesthesia Consultants of California in Escondino, and Pam Alexander, administrator of Northwest Arkansas Anesthesiologists in Jonesboro, Ark., recommend that anesthesia providers be trained (or reminded) to pay special attention to 10 areas when documenting their cases.

1. Physical status modifiers. All anesthesia services must include the procedure code as well as a physical status modifier describing the patients condition. The P1(a normal healthy patient) and P2 (a patient with mild systemic disease) modifiers are self-explanatory and do not require additional information. Documentation supporting a patients classification as P3 (a patient with severe systemic disease) or above must be evident before insurance carriers will reimburse at a higher level because of the risk factors involved with treating the patient. Fuqua says that the anesthesia records at some facilities allow the anesthesiologist to document the physical status and include space for the doctor to itemize what constitutes the patients status.

2. Details, details. Simply writing exploratory laparotomy or exp lap for resection, repairs or other similar procedures is not acceptable to many insurance carriers, and makes the coders job much more difficult. The more specific the anesthesia provider is about what takes place, the more accurately it can be coded and the more appropriate the resulting reimbursement will be. As Fuqua points out, patients rarely go into surgery without something specific being wrong with them.

3. Use those modifiers. The Health Care Financing Administration (HCFA) and the American Medical Association (AMA) have established many modifiers that provide more details about the services provided. Requirements for using modifiers may vary by carrier or by geographic area, so coders should always be sure to follow local guidelines. Modifiers follow the procedural code on the anesthesia record, and can describe circumstances such as a discontinued procedure (-53), repeat procedure by the same physician (-76) or distinct procedural service (-59). Most Medicare modifiers found in HCPCS describe who provided the service, such as -AA (anesthesia services performed personally by anesthesiologist) or -QZ (CRNA service: without medical direction by a physician). One of the newest modifiers some practices are now using is -QS to indicate monitored anesthesia care (MAC) service. Complete lists of modifiers with their definitions are in Appendix A of CPT 2000, and in the introduction of HCPCS 2000.

4. Pain management requests. Surgeons will often request that patients have some type of postoperative pain management care following a procedure. Alexander says the anesthesiologist may [...]