Anesthesia Coding Alert

The Health Care Financing Administration (HCFA) guidelines state that a medically directing anesthesiologist may perform other duties concurrently, such as performing periodic rather than continuous monitoring of an obstetrical patient, checking or discharging patients in Post Anesthesia Care Unit (PACU), and coordinating scheduling matters. Because of thisand because of the number of simultaneous cases that may require anesthesiaits common for a medically directing anesthesiologist to share time on a case with one or more other members of the same anesthesia-providing group.

Mryl Smith, coding manager with Healthpac Computers, a physician and hospital billing service in Savannah, GA, that mainly handles anesthesia and radiology claims, says that before a case can be considered medically directed, HCFA mandates that the anesthesiologist meet several criteria, sometimes called the seven rules of medical direction. The physician must:

1. perform a pre-anesthesia examination and evaluation;
2. prescribe the anesthesia plan;
3. personally participate in the most demanding
procedures of the anesthesia plan, including induc-
tion and emergence;
4. ensure that any procedures in the anesthesia plan
that he or she does not perform are performed by a qualified anesthetist;
5. monitor the course of anesthesia administration at
intervals;
6. remain physically present and available for immedi-
ate diagnosis and treatment of emergencies; and
7. provide indicated post-anesthesia care.

Once a case has been deemed medically directed, the question for many coders is: How should the shared services be billed? The answer: It depends on which member of the anesthesia team performs which services at which times.

Members of the Georgia Society of Anesthesiologists (GSA) wanted to be sure they were coding correctly, so they decided to go straight to the source. The Georgia Society of the American Society of Anesthesiologists (ASA) submitted a list of questions to Medicare to try and make sense of the OR rules, says Judy Chesin, president of the Georgia Anesthesia Administrators Association (GAAA). Were beginning to get answers back from HCFA, and the rules arent as vague as we originally thought. Having concrete answers to common situations makes it easier for us to code procedures right the first time, and speed up the reimbursement process.

The following questions and answers are based on information GSA developed with Cahaba Benefits Administrators, Georgias Medicare carrier. The information applies to anesthesia practices in Georgia and possibly other states with Cahaba Medicare. Chesin recommends that coders check with their local carriers for specific requirements in their state, and consider using the Georgia guidelines to clarify these issues with other Medicare carriers.

Frequently Asked Questions and Answers

1. Concurrent Care:

Q: If one medically directed case ends at 10:01 a.m. and another begins at 10:01 a.m., can these cases be considered to be concurrent for medical direction purposes?
A: No, they are not considered to be concurrent.

2. Shared Providers:

Q: When one member of a group practice starts a case and another member of the same group assumes medical direction for the remainder of the case (the intraoperative handoff), how should the case be billed?
A: HCFA allows this type of intraoperative handoff, with the billing submitted in the name of the provider involved with the case for the longest period of time (which is usually the simplest way to handle the situation). However, HCFA also stated in the March 1998 Medicare Advisory newsletter that On occasion, a qualified anesthesiologist or CRNA will be relieved from anesthesia care by another qualified anesthesia provider. When this occurs, the anesthetist that started the case should bill for the entire case. This type of situation may occur when the medically directing anesthesiologist is needed to place lines or epidurals in the holding area, or when he or she is leaving for the day and has another provider assume responsibility for the case.

Some states require that intraoperative handoffs be billed according to the amount of time each physician spends on the case instead of billing it under a single name. For example, if one anesthesiologist begins a case at 10:20 a.m., is replaced by another anesthesiologist at 10:40 and the case ends at 11:25 a.m., the first anesthesiologist will bill for 20 minutes of time and the second will bill for 45 minutes. Its important that coders know which method their state requires so they can file accordingly.

The specific codes used to bill intraoperative
handoffs will vary, depending on the particular situation. Modifiers that may be used include -AA (anesthesia services performed personally by anesthesiologist) or
-QK (medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals).

3. Medical Direction is Personally Performed:

Q: An anesthesiologist is directing several anesthetists employed by the group. At the end of the day, when only one case is still under way, the medically directing anesthesiologist relieves the one remaining anesthetist and finishes the case personally. Should the case be billed as medically directed, personally performed, or split between the two?
A: A case cannot be billed as personally performed
(-AA, anesthesia services personally performed by anesthesiologist) unless it is entirely performed by the billing anesthesiologist. Therefore, the case should be billed as medically directed (-AB, medical direction of own employee[s] by anesthesiologist).

Q: If an anesthesiologist is personally performing the anesthesia services and is relieved by a medically directed anesthetist (whose medical direction is being provided by another physician member of the same anesthesiology group) for a lunch break, how should the case be billed?
A: The case should be billed as medically directed (-AB).

Q: In the previous questions case, how should the
medically directing anesthesiologist document the case?
A: The medically directing anesthesiologist should sign the anesthesia record and note his or her continuous availability during the time the case was medically directed. The personally performing anesthesiologist should also document the periods that were personally performed and note the time when he or she left for lunch break and the case became medically directed.

4. Medically Supervised:

Q: An anesthesiologist is medically directing a nurse anesthetist and is present for intubation, which has been documented in the anesthesia record. However, an hour into the case a patient in another room goes into cardiac arrest, and the anesthesiologist must devote time to that patient. How is the original case coded?
A: When the anesthesiologist leaves the first case to care for the patient in cardiac arrest, the original case is no longer medically directed. It is now medically supervised, and should be coded with -AD (medical supervision by a physician: more than four concurrent anesthesia procedures).

Q: When should the case be billed as -AD (medically supervised by a physician with more than four concurrent anesthesia procedures) by the physician?
A: Cases are considered to be medically supervised by the physician when more than four cases are under the direction of one physician simultaneously. This is a different situation from the previous question because in that scenario the physician did not acquire a fifth room for supervision, but rather was unable to continue medical direction of four or fewer rooms for another reason.

Smith warns coders in other states not to assume that the Georgia guidelines automatically apply in their area. Billing coders should check with their local fiscal intermediary to be sure these guidelines apply to their practice.

5. Non-medically Directed:

Q: If an anesthesiologist is medically directing several cases simultaneously and (due to some intervening factor) is unable to be present at emergence, is not immediately available for some portion of a case, or fails to note periodic monitoring on the chart, can the case be billed as -QZ (CRNA service: without medical direction by a physician) as if the services were provided by a non-medically directed CRNA or AA?
A: Yes, the services of the anesthetist should be billed as non-medically directed, or -QZ.