Anesthesia Coding Alert

See if your anesthesiologist’s service falls in these categories.

Each time you file a claim for an anesthesiologist, you must denote whether the case was medically directed or medically supervised, based on how many concurrent cases the provider was involved with. The anesthesiologist should not normally provide services to other patients while medically directing a certified registered nurse practitioner (CRNA) or other anesthesia provider, but there can be exceptions to this stance.

These exceptions — known within the anesthesia world as the “permissible sins” — are outlined by CMS as services that can be performed simultaneous with medical direction, provided that the services don’t take away from the anesthesiologist’s ability to medically direct the original cases.

These “permissible sins” are:

• Addressing an emergency of short duration in the immediate area
• Administering an epidural or caudal anesthetic to ease labor pain
• Periodic rather than continuous monitoring of an obstetrical patient
• Receiving patients entering the operating suite for the next surgery
• Checking on or discharging patients from the post anesthesia care unit
• Coordinating scheduling matters

Fully understanding these “sins” includes several gray areas of interpretation. Primary among those is the question: What qualifies as “short duration”? The answer is a judgment call since specifics aren’t outlined, but read on for some expert advice in making that decision from Kelly Dennis, MBA, ACS-AN, CAN-PC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Florida.

Look to the Documentation

Some services are fairly easy to justify as emergencies of short duration, which means you shouldn’t have trouble with reimbursement. Two common examples can be intubation for adults in respiratory arrest and for infants with meconium (31500, Intubation, endotracheal, emergency procedure).

Other examples include treating nearby PACU patients with problems such as hypotension (I95.-, Hypotension), dyspnea (R06.00 or R06.09), acute respiratory distress syndrome (J80), or inadequate pain medications.

Including a diagnosis such as respiratory arrest or meconium leaves little doubt to the payer that you’re reporting an emergency situation. Be sure to educate your anesthesia providers, however, in terms of which services are accepted as emergencies of short duration while other services that seem similar might not be.

Example: The guidelines state that the physician can administer an epidural or caudal anesthetic to a patient in labor while medically directing several cases. Some coders say their physicians have a hard time realizing that an epidural steroid injection (ESI) — which usually takes less time than a laboring epidural — does not constitute “short duration.”

The difference in the two epidural situations is that the ESI is an elective procedure the physician can administer at any time; a laboring epidural cannot be delayed until a three-hour case is finished.

CPT^® includes many codes for ESIs, depending on the circumstances. Common ones include 62320 (Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance); 62322 (... lumbar, sacral (caudal); without imaging guidance; 64479-+64484, various sites for (Injection, anesthetic agent and/or steroid, transforaminal epidural).

Consider Setting a Definition for Your Group

How you interpret “short duration” can depend on the size of the facility where you work. Can a physician who is helping in the ED or ICU of a large hospital really get back to the OR quickly enough if needed in an emergency? In some hospitals, the ICU may be very close to the OR. In others, the departments could be in separate wings. It really comes down to a decision the group must make.

If you’re trying to define it for your group, consider these perspectives:

• The service should take no more than a minute or two for the anesthesi­ologist to reach the patient.
• The service should be no longer than the amount of time the patient could survive without oxygen.
• Remember that in anesthesia, an “emergency” is defined as a threat to the patient’s life or limb.

Pros: One obvious positive aspect of creating your own definition is that everyone in your group should be on the same page in terms of following the guidelines. Supporters also believe the guidelines could come in handy during an audit. If questions regarding “short duration” come up, you can point to your group’s policy and explain that you’ve developed your own definition or criteria since an official, clear definition does not exist.

Cons: Once you have a written policy, everyone must adhere to that policy exactly. Also consider that carriers might not agree with your rule and that, if you deviate from it in any way, you broke medical direction based on your own policy.

Final thought: If you’re uncertain regarding whether a situation meets the criteria for a medical direction exception, always check with your local payer for clarification before submitting the claim.