Anesthesia Coding Alert

Audits whether conducted internally or by an outside consultant always cause stress and headaches, but many coders say the secret to making the process as painless as possible is paying attention to a few key areas every day.

When a postoperative diagnosis is more descriptive of or relevant to a procedure, coders should use it instead of the preoperative diagnosis, says Kelly Dennis, CPC, EFPM, owner of the consulting firm Perfect Office Solutions in Leesburg, Fla. This often happens when the surgeon realizes that something different should be done once the patient is in the operating room, and changes plans accordingly.

For example, a patient could go into surgery with a preprocedure diagnosis of pelvic mass (789.30, Abdominal or pelvic swelling, mass, or lump; unspecified site), but the surgeon sees that it is an ovarian cyst once the procedure begins (620.2, Noninflammatory disorders of ovary, fallopian tube, and broad ligament; other and unspecified ovarian cyst). You should report the more accurate postprocedure diagnosis because of its accuracy, even if it doesn't change the course of anesthesia or the anesthesiologist's reimbursement.

More than one supporting diagnosis for a particular case may be required, depending on the situation and the carrier. (Many carriers require three or four documented diagnoses for patients with a physical status of P3 or higher.) Although having multiple diagnosis codes is not always as important in anesthesia billing as in other specialties, Emma LeGrand, CCS, CPC, office manager of the physician group New Jersey Anesthesia Associates in Florham, N.J., says additional diagnoses may help justify an anesthesiologist's presence when you bill MAC (monitored anesthesia care) for endoscopic or noninvasive procedures that do not usually warrant anesthesia.

For example, most patients do not require anesthesia before an MRI for a bone marrow study (76400, Magnetic resonance [e.g., proton] imaging, bone marrow blood supply). But if the patient is a young child or has complicating factors such as claustrophobia (300.29, Phobic disorders; other isolated or simple phobias) or Parkinson's disease (332.0, Parkinson's disease; paralysis agitans), anesthesia may be used to help make the test go more smoothly.

If a secondary diagnosis is given, Dennis says, it's not a bad idea to include it, though she adds, "I would not consider it a huge problem in an internal audit if the coder only listed the diagnosis related to the problem."

Because time units are such an important part of the anesthesia billing equation, check patient records to ensure that the reported times make sense.

"I visually look at the times [in the patient's record] to make certain that the anesthesia start and stop times are reasonably close to the surgical start and stop times," Dennis says. "I've caught many time errors this way."

Procedure start and stop times should also be exact rather than rounded to the nearest five-minute increment, LeGrand says. Medicare requires exact reporting of minutes even if the anesthesiologist's time units are billed in 10- or 15-minute increments. Rounding times up or down is also fraud, which can lead to steep fines, loss of the physician's license and even imprisonment.

A third consideration when checking times is that the physician or other anesthesia provider must be present for any face-to-face time that is billed. All criteria associated with any "physician performance" modifiers should also be met and documented, such as modifiers -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; and others.

Medication or medical-history facts may be buried elsewhere in the patient's record but can have a bearing on anesthesia.

If a patient is on medications for an acute or chronic condition such as diabetes (250.XX, Diabetes mellitus), an appropriate code for this condition should be included with the procedure's supporting diagnosis code. "This information could make an impact on the patient's physical-status modifier or the type of anesthesia administered to the patient," LeGrand says. "You can also query the physician for history of diagnosis and have him document the conditions."

Information in the patient's medical record about past medical conditions can also be important to a coder, even if the patient has completed treatment. The list of pertinent conditions and treatments is long, but it includes abdominal aortic aneurysm (441.4, Abdominal aneurysm without mention of rupture), vascular problems (such as 440.9, Generalized and unspecified atherosclerosis; or 444.22, Arterial embolism and thrombosis; of arteries of the lower extremity), a history of malignancy (such as history of colon cancer, V10.05, Personal history of malignant neoplasm; gastrointestinal tract; large intestine) or hypertension (401.9, Essential hypertension; unspecified).

You should double-check to make sure each patient record accurately documents the physician's level of involvement with the case medically supervising, medically directing, teaching, or personally performing anesthesia services. (See page 68 for a list of the criteria for each level of involvement.)

The physician's role in induction, emergence and key portions of the anesthetic administration should also always be documented. "One way to document the physician's presence at key portions is to initial the time line on the anesthesia record," Dennis suggests. "Another way would be to make actual notes in the margin. If it's not possible to change the anesthesia records, the group might consider buying a rubber stamp to use."

The purpose of an audit is to check the accuracy of patient records, and mistakes or inaccuracies are bound to surface. So what kinds of steps should you take to deal with the mistakes and ensure they don't happen again?

First, LeGrand and Dennis both recommend conducting internal audits each quarter and hiring a consultant to perform an audit annually. Dennis adds that it is important for the auditor to be a certified coder. Other tips for getting back on track after finding mistakes during an audit include: