Anesthesia Coding Alert

Nugget: Thorough documentation can help you get reimbursed for PACU time that goes beyond the standard seven-minute rule time limit.

Anesthesia billing time ends after the patient has been in the post anesthesia care unit (PACU) for seven minutes, but sometimes more than seven minutes of care is needed for recovery time. Services such as prolonged care, pain blocks and ventilator management can go beyond standard PACU care. The key to getting reimbursed for nonstandard PACU care is thorough documentation.

The anesthesiologists must clearly document why they may continue to charge for more than seven minutes after a patient is moved to recovery, says Robin Fuqua, CPIC, a certified insurance coder with Anesthesia Consultants of California in Escondino. Medicare has a compliance guideline related to PACU time known as the seven-minute rule. The general assumption is that anesthesia care should not be necessary for more than seven minutes after a patient has been released from the operating room to the recovery room. We do allow charges for extra time in special circumstances, says Fuqua. We just need all the proper backup documentation of the situation before we try to send the claim through.

Standard vs. Nonstandard Care

Scott Groudine, MD, associate professor of anesthesiology at Albany Medical Center in Albany, N.Y., and chairman of governmental, legal and economic affairs for the New York State Society of Anesthesiologists, agrees with Fuqua that it is possible to get paid for nonstandard PACU care, as long as the anesthesiologist documents thoroughly. Some carriers will pay for postoperative pain blocks administered in the PACU, but others wont, he says. If the patient is discharged from the PACU but cannot be transferred to an ICU because of a bed situation, it should be possible to bill critical care codes for this patient if additional services are required. It would be prudent to thoroughly document that the patient has recovered from anesthesia before attempting to code this way.

Groudine says that all standard procedures done for routine postoperative care are included in the global anesthetic fee, so they are not coded and billed for separately. He cites several procedures that are usually included in the standard fee: signing out the patient to PACU nurses, placing oxygen, restarting peripheral IVs, placing oral and nasal airways, managing minor blood pressure deviations, administering basic PACU pain control, and ventilator management until the patient is discharged from PACU.

Billing for the Nonstandard Care

Two options are available for billing major postoperative problems; check with your local carriers to see if either method is accepted in your area.

1. Bill the individual procedures as separate and distinct services. Joan Tak, director of operations for the 42-physician group Anesthesia Consultants of New Jersey in Somerville, cites prolonged ventilator management as an example of this billing. Although some carriers may not pay for it, she says long-term vent care in the PACU can be billed with code 94656 (ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; first day) along with modifier -59 (distinct procedural service) when backup documentation supports its necessity.

2. Bill the time required to care for the problems using discontinuous anesthesia time. For example, the procedure ends at 13:15, and the patient goes into hypotensive shock at 14:10. Some insurance carriers and most Medicare carriers would reject the claim if it is billed as critical care, code 99291 (critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) or code 99292 (critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes). Instead, some carriers may allow the time required to deal with the hypotensive situation to be documented and billed as discontinuous time. Since billing for discontinuous time is still a new area of anesthesia reimbursement, check regulations with your local carrier before attempting to bill a claim this way.

Whatever method is used to bill for these types of situations, the patients record should clearly indicate that the care is not routine postoperative care. We dont bill for nonstandard PACU care very often, Tak acknowledges, but its important to know what each carrier will allow in case the situation comes up. You want to be sure the anesthesia provider gets credit for any extra time spent managing a patient before he or she is transferred from the PACU to the critical care or intensive care unit, but also be sure your charges are appropriate and that you have the documentation to justify anything you bill.