Anesthesia Coding Alert

With so many requirements related to anesthesia documentation, its no wonder patient records dont always include the necessary information. But by educating anesthesia providers about what documentation is required, coders can make their job easier while helping providers achieve the most appropriate reimbursement for their services.

Documentation requirements can be grouped into two areas: (1) those items mandated by insurers or other regulatory bodies, and (2) those items that may not be necessary but that can ease the work of coding staff and improve your chances of receiving adequate reimbursement.

Code to Meet Insurer Requirements

A couple of years ago, we hired consultants to visit our company, go through all our policies and procedures, and give us all the corrections we needed to make to become a Medicare-compliant billing office, says Robin Fuqua, CPIC, a certified insurance coder with the medical group Anesthesia Consultants of California in Escondido. Because Medicare is the strictest of all insurers, we felt that if we can satisfy its requirements we should be doing well enough for other carriers.

Common requirements from insurers can include:

Notes from the patients preoperative evaluation and postoperative visit;

Accurate times documenting the procedure;

Vital signs and documentation of administering and monitoring drugs;

Anesthesia personnel involved in the procedure;

Type of surgery performed and anesthesia administered; and,

Patient consent to anesthesia.

Following the consultants visit, Fuquas office made a number of changes to ensure that its documentation was more likely to comply with insurer requirements:

All physicians must account for their time on the anesthesia record. Insurers may assume that the anesthesiologist did nothing if there are no indications of checking on a patients vital signs throughout a procedure.

Physicians must circle notations in the anesthesia record of any lines placed and charged.

Any pre-existing condition (such as a history of myocardial infarction or cancer) making the procedure riskier or warranting an emergency charge must be documented in the remarks section of the anesthesia record or in the description line of the groups charge sheet. Emergency situations that need to be documented can include hemorrhage, sepsis, vascular compromise, a ruptured appendix or other unanticipated circumstances.

Allow a maximum of seven minutes between the time a patient enters the post anesthesia care unit and anesthesia is discontinued, so the anesthesiologists stop time is easily documented. The only exceptions are for services assigned 13 or more base units (such as major lung, back or heart surgery) or when special circumstances require the anesthesiologist to write a short description on the anesthesia record or charge sheet. The physicians description is then summarized on the HCFA 1500 form for the insurance company.

Update computer databases to reflect changes to the base unit values assigned to many standard anesthesia codes in 2000. Fuquas group did this so they would be charging the appropriate number of base units for procedures. The groups goal is to make future changes on or before Jan. 1 of the year changes become effective.

Measure time accurately. Fuquas group counts time units in 15-minute increments, which is standard for Medicare and Medi-Cal of California, as well as some other carriers. Some practices switch to 10-minute increments after four hours, but this type of documentation is at the discretion of the group. Many groups charge on a minute-by-minute basis.

All physicians must complete any paperwork that might be submitted to an insurance company (such as anesthesia records and doctors progress notes) legibly. As Fuqua says, Medicares position is: If they cant read it, they cant verify what the doctor did. They say its our problem to provide them with legible records of treatment, not their problem to interpret scrawls.

Provide Additional Information

Many coders say that the more information you can include in the patients record, the easier coding for the procedure will be. A copy of the operating facilitys patient information sheet, copies of all insurance cards, and a copy of the facilitys authorization to treat the patient and release his or her records (with the patients signature) can all provide valuable information. In addition to such up front paperwork, a copy of the patients operative report can also prove valuable.

But sometimes the surgeon begins a procedure and realizes that the situation is different than he thought. For example, an exploratory laparotomy (49000, exploratory laparotomy, exploratory celiotomy with or without biopsy[s] [separate procedure]) may become a colon or small bowel resection (44202, laparoscopy, surgical; intestinal resection, with anastomosis [intra or extracorporeal]), or an ovarian cystectomy (58925, ovarian cystectomy, unilateral or bilateral) may become an oophorectomy (58940, oophorectomy, partial or total, unilateral or bilateral). Depending on the situation, the anesthesia and therefore the coding may have to be changed in light of the new information.

A good anesthesia record should document the post-operative diagnosis and the procedures actually performed, not just what was contemplated, says Scott Groudine, MD, associate professor of anesthesiology at Albany State University School of Medicine in New York. This provides the coder with the information needed to support the charges and coding. We always send our coders a carbon copy of our record.

Other beneficial information includes notes about past procedures the patient has undergone. For example, procedures such as previous coronary artery bypass graft (CABG) surgery or heart surgery should be noted in the record, especially if the patient is scheduled for open heart surgery including a repeat CABG or heart valve replacement. This situation could include codes for CABG 33533 (coronary artery bypass, using arterial graft[s]; single arterial graft) or 33512 (coronary artery bypass, vein only; three coronary venous grafts) with ICD-9 codes from the 414.xx family (coronary atherosclerosis; aneurysm of heart; other specified forms of chronic ischemic heart disease; chronic ischemic heart disease, unspecified) and V45.81 (aortocoronary bypass status) for the previous CABG.

So how do you track down these extra tidbits of information? Working closely with the anesthesia providers to ensure details are included in the chart can make a big difference. Other coders find that having computer access to the patients records or admitting history and physical can provide tremendous amounts of helpful information.

Realize the Difference Documentation Can Make

The more information a physician can include in the patients record, the more extensively the claim can be coded. For example:

A patient arrives at the hospital by ambulance late at night, status post motor vehicle accident (s/p MVA). He presents with multiple fractures, including one of the inter-trochanteric femur. The patient is over 70 years old and has hypertension (HTN) and multiple coronary artery disorders (CADs) as underlying conditions. The anesthesiologist placed an arterial line for monitoring purposes while the femur was being repaired in an open fashion.

The open femur repair for a P3 level patient (a patient with severe systemic disease) at higher risk because of the HTN and multiple CADs is coded 27244 (open treatment of intertrochanteric, pertrochanteric or subtrochanteric femoral fracture; with plate/screw type implant, with or without cerclage) -P3.

The late-night service is coded 99052 (services requested between 10 p.m. and 8 a.m. in addition to basic service). Code 99100 (anesthesia for patient of extreme age, under one year and over seventy) is used to designate that the patient was over 70 years old. The requested emergency service is coded 99140 (anesthesia complicated by emergency conditions [specify]), and the arterial line is coded 36620 (arterial catheterization or cannulation for sampling, monitoring or transfusion [separate procedure]; percutaneous). The description P3 = HTN and CAD, s/p MVA, trauma appears on the HCFA form to explain to the insurance carrier why the service was riskier than normal and considered an emergency. The more detail you can include (up to four ICD-9s), the easier it is to justify your qualifiers for classifying the patient as P3 or above, or to justify emergency or other special services.

Another common coding scenario involves patients with blood pressure problems. In this case, documentation must specify whether the patient has hypertension or elevated blood pressure without the presence of hypertension for the condition to be coded correctly.

These terms are similar, Groudine says, but hypertension is more likely to be a chronic state and therefore a medical condition, whereas elevated blood pressure is just a physical finding. Hypertension can justify coding with a P-3 status, but a temporarily elevated blood pressure is not a systemic condition warranting a higher level of physical status.

Asking physicians to list the patients medications in the chart can help coders determine whether a condition such as elevated blood pressure is a chronic condition that justifies higher-level codes, or a temporary condition due to stress or another specific situation.

Include Every Detail

No matter how small a detail may seem, including it in the patients chart may mean the difference between appropriate or less-than-ideal reimbursement. In many cases, coding staff need to be sure all the necessary details as well as any additional details that may support payment are documented.

If the doctor has forgotten to detail anything important, hold on to the charge until the clarification can be made, Fuqua advises. Its always better to delay getting the charge billed and have it be correct when it is done than to make incorrect assumptions and run the risk of error. Its too late to say, Oops! if an auditor decides to come in and look at your documentation.