Anesthesia Coding Alert

Documentation is such an important area of anesthesia coding that studying the ins and outs of it could easily fill an entire issue of Anesthesia and Pain Management Coding Alert. Last month we looked at three prime areas to focus on to ensure your providers' documentation is up to par start and stop times, adequate signatures, and complete patient diagnoses.

 Now we'll look at four more important checkpoints to home in on to make your documentation and coding as accurate as possible.

 All anesthesia coding must include a performance modifier to indicate whether an anesthesiologist, a CRNA or a resident handled the case, and in what capacity. Choices from a physician perspective include -AA (Anesthesia services performed personally by anesthesiologist), -AD (Medical supervision by a physician: more than four concurrent anesthesia procedures), -QK (Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals), -QY (Medical direction of one certified registered nurse anesthetist [CRNA] by an anesthesiologist) and -GC (This service has been performed in part by a resident under the direction of a teaching physician).

 An anesthesiologist must meet several criteria (often referred to as the Seven Rules of Medical Direction) before he or she can bill a case as medically directed. Clear documentation ensures that the anesthesiologist:

 

performed a pre-anesthesia examination and evaluation
 

prescribed an anesthesia plan
 

personally participated in the most demanding procedures of the anesthesia plan, including induction and emergence
 

ensured that any procedure in the plan that he or she did not perform was performed by a qualified anesthetist
 

monitored the course of anesthesia administration at intervals
 

remained physically present and available for immediate diagnosis and treatment of emergencies
 

provided the indicated postanesthesia care.

 "In my opinion, the most problematic of the 'seven rules' is 'personally participated in the most demanding portions, including induction and emergence,' " says Eileen Ledbetter, RHIT, CS, CPC, anesthesia and pain management coder at Lahey Clinic in Burlington, Mass. "Induction can be documented in the chart as a specific time. Emergence occurs over a span of time that may continue into the recovery room. Documenting personal participation during this span of time may be difficult."

 Ledbetter's group includes a time line on the patient record to simplify documentation. The anesthesiologist indicates his or her presence at key portions of the procedure along the time line. She also recommends including definitions of ambiguous terms such as "immediately available," "immediate area" and "emergency of short duration" in your compliance plans so providers can be consistent in their interpretations of the criteria.

 Once you have met all of the criteria, you must ensure that the physician was involved in a maximum of four concurrent cases before they can be billed as medically directed. If the physician adds a fifth concurrent case to the picture, you should code them all as medically supervised instead of medically directed. The same holds true if the physician starts a case while medically directing code his new case as personally performed, and the others as medically supervised.

 Keep in mind that the rules are different in teaching facilities, where an attending physician can medically direct only two residents or interns simultaneously.

 "We have a checklist beside one of the signature places to remind the physicians what needs to be documented for medical direction," says Tammy Reed, billing manager for the anesthesia department of Oklahoma University Health Science Center in Oklahoma City. "They have to initial each of these places as well as document the step in the anesthesia record."

 Ledbetter recommends asking yourself questions such as "Is the documentation clear? Can I judge from the record if the physician has complied with all the rules? If not, how can it be fixed so it will be clear in the future?"  

 "Sometimes the problem can be corrected with physician education," she says. "Other times it takes a more drastic action such as revamping the anesthesia record's format to make it easier for the physicians to comply with requirements."

Checkpoint 2: Prove Medical Necessity for MAC

 Anesthesiologists often use monitored anesthesia care (MAC) during procedures instead of administering general anesthesia or a block. But just because MAC is common doesn't mean it's always easily reimbursed many carriers have policies with detailed lists of procedures that are acceptable for MAC anesthesia. It gets even more complicated when the policies also limit the acceptable diagnoses to go with each procedure, which makes documentation of the patient's condition and the situation even more important when it's time to code.

 "MAC pays the same as general anesthesia, so carriers want to know if MAC was truly necessary for the patient before they pay for it," Ledbetter says. "The carrier may feel that the surgeon could have just sedated the patient, which is why they want documentation or a diagnosis code that explains why MAC was the chosen mode of anesthesia."

 Sometimes the procedure itself helps show why MAC was used. Cataract removals, for example, don't need more than MAC. But carriers also think that some cases such as excision of some small, superficial lesions, breast biopsies and some eye procedures don't even merit the use of MAC, which is why your documentation should clearly support its need.

 How do you handle coding if the anesthesiologist administers MAC for a case that doesn't meet the carrier's procedure or diagnosis requirements? Ledbetter considers herself fortunate because she doesn't run into MAC reimbursement problems, but she says that having the proper documentation with MAC is especially vital in these cases.

 "Documentation by the surgeon requesting MAC services or the anesthesiologist noting why MAC was necessary is acceptable," she says. Ledbetter also recommends checking whether a diagnosis or other documentation that could support MAC might have been missed in the patient record. If not, ask the surgeon or  anesthesiologist to write an addendum stating medical necessity for MAC in that case.

 Many patients have postoperative blocks or other types of pain management following their procedures. This is usually considered part of the global surgical fee but can be separately coded and reimbursed by the anesthesia provider if the situation merits it and your documentation and approvals are in order.

 Documentation should support why pain management was beyond the scope of the surgeon and needed to be handled by the anesthesiologist, Ledbetter says. For example, the surgeon may request a block or epidural and pain management follow-up for a joint arthroplasty replacement patient. Get the surgeon's request in writing and have appropriate procedure notes from the anesthesiologist to help justify separately coding for the service.

 When you code the postoperative pain service, append modifier -59 (Distinct procedural service) to the pain code to distinguish it from the anesthesia used during the procedure itself. Common pain management codes are usually chosen from the ranges 62310-62319 and 64400-64450 for the initial block or epidural. Code follow-up care of 62318 or 62319 with subsequent hospital care codes 99231-99233.

 Most surgeries take place as scheduled, so coding is fairly cut-and-dried. But how should you code and get reimbursed for the anesthesia provider's involvement in a case that was canceled? Your best option for handling the situation may hinge on the carrier's guidelines, but coding may also depend on how far along the case was before it was canceled.

 Before attempting to code for the case and receive reimbursement, you must know why the case was canceled. If the patient decided not to have an elective surgery performed or if a medical complication prevented the surgeon from proceeding, document it clearly on the patient's chart. Clear documentation of the anesthesia team's involvement prior to cancellation is also necessary for reimbursement.

 If the case is canceled before induction, you have three coding options:
 

  Report an appropriate E/M service (99201-99205 or 99211-99215 for outpatients, or 99231-99233 for inpatients) instead of an anesthesia code. Ledbetter recently had a case in which the anesthesiologist spent some time with the patient and performed a brief pre-op exam before it was canceled. "He coded it to a low-level subsequent hospital visit (99231)," she says. "I went back and pulled the record to be sure he met the three key components for that level before we coded it."
 

Report a consultation code (99241-99245 or 99251-99255). Ledbetter says this approach could work, but the documentation needs to support using a consult code. In other words, the anesthesiologist must document in the record that Dr. A requested a consult on this patient. The anesthesiologist should also document his findings and that he reported these findings to Dr. A. Some coders recommend adding modifier -53 (Discontinued procedure) to the consult code, but others believe modifier -52 (Reduced services) is more appropriate. Ask the carrier about its guidelines for consult codes and modifiers. If you report a consult, be sure you meet the Three R's to back it up a written request from the surgeon, documentation that the anesthesia consult was rendered, and a written report advising the surgeon of the anesthesiologist's opinion.
 

Skip coding the encounter, especially if the case is rescheduled within the next few days. "If I don't find enough documentation to support an E/M level, I don't try for reimbursement," Ledbetter says. She also suggests setting department guidelines for these types of cases so you can treat them consistently.

 When cases are canceled after induction, many coders report whatever anesthesia code would have applied to the case and append modifier -53. You can still code for any invasive lines (such as arterial lines, CVP lines or Swan-Ganz catheters) that were placed prior to cancellation. The primary diagnosis code on the claim should reflect the reason the surgery was canceled; the second diagnosis should represent the initial reason for surgery.

 Anesthesia coders don't have handy reference lists of bullets to help ensure they cover all the bases, which is part of the reason why documentation is so difficult. The Seven Rules of Medical Direction offer some guidance, but you're still on your own with everything else related to documentation.

 "The Medicare program contains the most specific requirements for billing anesthesia services, and many other carriers incorporate these rules," Ledbetter says. "We can help physicians understand all the complexities of documentation through reviews and education, but the doctors have the ultimate responsibility for documenting correct information. Set up an education and compliance plan and then keep track of all that you do. Just having a compliance plan in place helps keep you on the right path with Medicare and other carriers."