Anesthesia Coding Alert

‘Cut and paste’ can be easy, but costly.

Many specialties run into snags with their E/M coding when using electronic health records (EHRs), but even non-E/M anesthesia practices aren’t immune to snafus in three other areas.

“Anesthesia services don’t lend themselves to the same type of complexity-creep as do E/M services,” wrote Tony Mira of Anesthesia Business Consultants in a recent blog post. “The use of actual time in the valuation of anesthesia is an advantage, in this instance.”

However, Mira cautioned that anesthesia has its own areas in which EHR technology can lead to reporting errors. Watch the following three areas to ensure your reporting stays accurate and error-free.

Area 1: Accurate Recording Times

Some electronic record systems default to the time of documentation and don’t allow you to override the system to indicate the time the service actually was provided. This can lead to irregularities in start/stop times such as intubation seeming to happen after the surgical procedure has begun.

Solution: “There’s usually an area where you can enter notes,” says Kelly Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I,  owner of Perfect Office Solutions in Leesburg, Fla. “If you know that your system is putting information in the wrong order  there isn’t a software fix, make a note about the issue and file it with your compliance documentation.”

Area 2: Cut and Paste Errors

Copying and pasting information from one part of a patient’s record to another can be tempting because it speeds up the process and keeps you from repeatedly entering the same information.

Red flag: Problems can arise when your charts begin to resemble cookie-cutter documentation because of the similarities, or when you copy/cut/paste incorrectly. You can also find yourself coding from misinformation if the surgeon gets into the OR and performs a different procedure than originally anticipated. The surgeon would modify the hospital EHR in that situation, so you need to verify that the anesthesia record correctly reflects the latest documentation.

“Always [have the physician] review the information before signing the report,” Dennis advises. And, as a coder, double check your anesthesia provider’s information to verify that it coincides with other information for the patient—including details in other anesthesia records and the surgeon’s record.

Area 3: Documenting for Multiple Providers

Anesthesia providers often share oversight or services during a procedure. For example, one anesthesiologist might induce the patient and hand the case off to another anesthesiologist or CRNA. The EHR might not allow you to record services from a second provider if the first physician didn’t sign out.

“I’ve seen systems that allow for multiple providers, but the information must be entered,” Dennis says. “If the software doesn’t allow you to enter multiple providers, make a notation. All systems have an area where you can make notes.”

Lesson to learn: EHRs can make documentation and coding simpler in many respects, but also make it easier to document patient care with incorrect information. Even the Office of Inspector General (OIG) writes in a December 2013 report on hospital EHR technology safeguards that “Experts in health information caution that EHR technology can make it easier to commit fraud.”

Resource: To read the full OIG report, go online to http://oig.hhs.gov/oei/reports/oei-01-11-00570.pdf.