Anesthesia Coding Alert

Add these 4 items to your ‘don’t miss’ list when checking procedure notes.

Some of the smallest details tucked into a patient’s anesthesia and surgical records can make a big difference in how you code the case. You won’t find everything you need on the charge ticket " dig deeper into the procedure records themselves for items that can bump up your bottom line, such as medical direction, physical status, and more.

1. Clue In to Medical Direction Status

One vital piece to your anesthesia coding is documentation supporting the provider’s role in the case.

Did the physician personally perform the anesthesia service? Then be sure to append modifier AA (Anesthesia services performed personally by anesthesiologist) to the anesthesia code.

If the anesthesiologist is involved by medical direction, choose either modifier QY (Medical direction of one certified registered nurse anesthetist [CRNA] by an anesthesiologist) or QK (Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals), depending on the number of concurrent cases the physician directed. If the physician’s concurrent case load passes four, you’ll append modifier AD (Medical supervision by a physician: more than four concurrent anesthesia procedures).

The same holds for CRNA services, with the correct modifier depending on whether a physician medically directed the CRNA:

• Modifier QZ -- CRNA service: without medical direction by a physician
• Modifier QX -- CRNA service: with medical direction by a physician.

2. Verify Patient’s Physical Condition

The patient’s physical status can impact your provider’s service, just as underlying conditions can. CPT® defines the six physical status modifiers in the Anesthesia Guidelines:

• P1 -- A normal healthy patient
• P2 -- A patient with mild systemic disease
• P3 -- A patient with severe systemic disease
• P4 -- A patient with severe systemic disease that is a constant threat to life
• P5 -- A moribund patient who is not expected to survive without the operation
• P6 -- A declared brain-dead patient whose organs are being removed for donor purposes.

"Remember that the P3-P5 modifiers need to be supported," Cindy Hinton, CPC, CCP, CHCC, owner of Advanced Coding Solutions in Franklin, Tenn. "Look for chronic/active conditions that are impacting the patient’s status, such as hypertension, diabetes, or chronic atrial fibrillation."

Several P modifiers have an associated number of units that increases with the patient’s severity. "These are not billable to Medicare, but are covered by some payers," adds Diane Crosthwaite, CPC, CANPC, coding manager with abeo in Pasadena, Cal. The same holds true for qualifying circumstances add-on codes such as +99100 (Anesthesia for patient of extreme age, younger than 1 year and older than 70 [List separately in addition to code for primary anesthesia procedure]), +99116 and +99135 for anesthesia complicated by utilization of total body hypothermia or controlled hypotension, and +99140 (Anesthesia complicated by emergency conditions [specify] [List separately in addition to code for primary anesthesia procedure]).

3. Double Check Times of Care

Time is an important factor in calculating anesthesia fees, so providers must document the exact times of anesthesia care. Take note of start and stop times, as well as hand-offs between members of the anesthesia team (and which services each practitioner provided).

4. Watch for Postoperative Pain Measures

Although the charge ticket might not mention postoperative pain management, check for notes in the anesthesia record.

"Many times, blocks or epidurals are documented in the anesthesia record and qualify for separate billing, but somehow don’t make it to the charge ticket," Hinton says. "They’re prime examples of services that could get ‘left on the table’ if you review the charge ticket but not the anesthesia record."

Example: Reviewing the anesthesia record might show that the provider placed a block or epidural for post-op pain relief. If you have documentation that the surgeon requested post-op pain management and the provider did not use this epidural or block for the primary mode of anesthesia, the service might qualify for a separate charge.

Tip: If you’re able to report separate post-op pain management, remember to append modifier 59 (Distinct procedural service) to the block code.

"Remember, the anesthesia record is an official part of the medical record, but the charge ticket isn’t," Hinton says. "Charge tickets can be a helpful tool, but the documentation in the anesthesia record is the bottom line."

Editor’s note: For more on how the anesthesia record can help your coding, see "4 Vital Items You Don’t Want to Miss In the Anesthesia Record" in Anesthesia Coding Alert, Vol. 14 N. 5.