Anesthesia Coding Alert

Documenting time will be critical now that the Health Care Financing Administration (HCFA) sanctions billing for discontinuous time. In the past, many anesthesia groups simply wrote off the costs associated with the initial time block, even though they would probably be monitoring the patient from the time the epidural was placed. They didnt want to bill for something unless they knew it was approved. In a final ruling published in the Nov. 2, 1999 Federal Register, the Health Care Financing Administration (HCFA) officially sanctioned billing for this initial block of time as well as the time spent monitoring the patient during the actual procedure.

The ruling works in favor of anyone who has been cautious about billing for that initial block of time. How often the issue comes into play is highly location specific, says Jan Stewart, CRNA, ARNP, president of the American Association of Nurse Anesthetists (AANA). The term refers mostly to the practice of administering blocks or inserting invasive lines prior to the administration of anesthesia, she says. This practice is prevalent in some areas, and nearly nonexistent in others.

For example, an anesthesia professional may insert an epidural for a hysterectomy, but the procedure may not begin immediately. The time for setting up the epidural should be documented for billing, but the anesthesiologist should not code for the hysterectomy itself (00846 [anesthesia for radical hysterectomy], 00855 [anesthesia for cesarean hysterectomy] or 00944 [anesthesia for vaginal hysterectomy]) until it is documented with the time involved when it actually takes place. Otherwise, listing the procedure code for each time anesthesia staff is present makes it appear that two separate procedures were performed instead of one procedure over two blocks of time.

Document the Time

HCFA estimated in the ruling that the block of time before an interruption in service would generally be about 15 minutes, or one time unit. This beginning block of time should be noted separately on the billing form from the main block of time for the procedure itself. The times are added together for the final billing, but the claim should clearly document how the accumulated time was ascertained.

Scott Groudine, MD, associate professor of anesthesiology at Albany Medical Center in Albany, N.Y., says that documenting the blocks of time separately is imperative. For example, he says an anesthetist may place an epidural catheter for surgery from 8:30 a.m. to 8:45 a.m., perform a quick dilation and curettage (D and C) from 8:50 a.m. to 9:10 a.m., and then start surgery with the catheter at 9:15 a.m. The fifteen minutes from placing the catheter cant just be added to the start time of the surgery (where 8:50 a.m. plus 15 prior minutes would equal a start time of 8:35 a.m.), because now it appears that the person was placing an epidural and doing a D and C at the same time. Of course the provider was never in two places at the same time, but the billing records could indicate something differently and lead to a compliance problem.

In the above example, the time for placing the surgical patients epidural catheter would be noted as 8:30 a.m. to 8:45 a.m. The time for the surgery itself would be documented as 9:15 a.m. until it ends, and would be coded with the appropriate CPT or ASA (American Society of Anesthesiologists) code, depending on the surgery performed. The claim would be filed with the surgical CPT code and the total of anesthesia time spent during the two periods. The D and C patients chart would document the procedures time as 8:50 a.m. to 9:10 a.m., with procedure code 58120 (dilation and curettage, diagnostic and/or therapeutic [nonobstetrical]) and anesthesia code 00940 (anesthesia for vaginal procedures [including biopsy of labia, vagina, cervix or endometrium]; not otherwise specified).

Discontinuous time is not a common event in our practice, says Groudine. But with this new policy, we may be encouraged to do more epidurals while waiting for the operating room (OR) to become available. That can decrease our Medicare reimbursement since the time we would charge for work in a block room or holding area is less expensive than OR time, but handling cases this way will end up increasing our efficiency.

Note: Some local carriers may institute new documentation requirements to bill under this ruling. Groudine points out that this is a Medicare policy, so check with your local Medicare carrier for instructions on how to bill for discontinuous time in your area.