Anesthesia Coding Alert

Documentation is the anesthesia providers best friend its the key to reimbursement. But if your documentation of time, patient diagnoses, and physician signatures isnt up to snuff, it could be your worst enemy.

Be Consistent With Start and Stop Times

Much of anesthesia reimbursement is based on time units, so accurately documenting the time the anesthesiologist spends with patients is imperative.
 
We dont begin counting time when we first see the patient because at that point were conducting the pre-op evaluation thats part of the procedures base units, says Tammy Reed, billing manager for the anesthesia depart-ment of Oklahoma University Health Science Center in Oklahoma City. Instead, Reeds department uses the time that they begin preparing the patient for induction as the procedure start time. Sometimes we induce just prior to taking the patient to the OR, but some patients are already in the OR when the anesthesiologist induces them.

 In our group, anesthesia start time begins when the provider starts preparing the patient for induction and is in personal, continuous presence with the patient, says Eileen Ledbetter, RHIT, CS, CPC, anesthesia and pain management coder at Lahey Clinic in Burlington, Mass. We go this route because its in compliance with Medicare regulations and ASA guidelines.
 
Consistency is the biggest problem many coders face with documenting start and stop times. We try to stress using their own personal watches and not the OR clocks when theyre noting times, Reed says. The clocks in various OR rooms arent always synchronized, which means a provider can have overlapping times if he or she goes from one room to another. Unsynchronized clocks can affect concurrency issues and change whether an anesthesiologist is meeting the criteria for medical direction versus supervision (the physician can medically direct two, three or four concurrent cases; case loads that surpass four must be coded as medical supervision, a classification that comes with a pay cut).
 
You should also have clear documentation of when cases are passed from one member of the anesthesia team to another. For example, Dr. Jones may begin a case at 8:03. Dr. Brown takes over the case at 12:30 and finishes it at 16:35. Dr. Jones note reads, 12:30, case reviewed with Dr. Brown, and patient care turned over to Dr. Brown. Dr. Browns note reads, 12:30 case reviewed with Dr. Jones, and received patient case from Dr. Jones. Case ended at 16:35. The physicians write and sign these notes in the records comment area.

 We can usually tell by the writing when the change-over took place, but it still needs to be officially documented, Reed says.

 Reed recommends setting a policy of using military times for all cases (as in the example above). A concrete policy prevents having some providers reporting military time and others using nonmilitary time, and eliminates questions about whether times are a.m. or p.m., and whether a case crosses days.

 Its important to ensure that all anesthesiologists in the group are on the same page regarding start and stop times, Ledbetter says. Weve implemented a documentation/educational plan to ensure uniformity.

Use Specific Patient Diagnoses

The patients diagnosis and reason for surgery help justify the need for anesthesia, so be sure the patients record clearly states this information. The diagnosis and reason for surgery are usually the same for most scheduled surgeries, but this isnt always the case.
 
As a level-one trauma center, many times we just have multiple trauma as a diagnosis justifying surgery, Reed says. When the case begins, the patient actually has multiple internal injuries that should be coded individually (often related to diagnoses 959.0-959.8, various locations of Injury, other and unspecified) instead of reported with a generic multiple injuries code (such as 869.0, Internal injury to unspecified or ill-defined organs; without mention of open wound into cavity).
 
The more specific the diagnosis is, the more accurate your coding will be. Most claim forms allow space for four diagnoses, which allows you to report the current reasons for surgery as well as underlying conditions that increase the anesthesia providers risk (for example, malignant hypertensive heart disease with or without heart failure, 402.00-402.01, or diabetes with renal manifestations, 250.4x). If you report multiple diagnoses on the claim, make sure the leading diagnosis code supports the reason for surgery.
 
Documenting multiple diagnoses can also help justify a patients higher physical status classification (known as P status; these six modifiers are outlined in CPTs anesthesia guidelines). Reed says, however, that multiple diagnoses arent always necessary for high P-status patients. For instance, a patient with a ruptured abdominal aortic aneurysm (441.3, Aortic aneurysm and dissection; abdominal aneurysm, ruptured) would qualify for a higher P-status modifier without an additional diagnosis.
 
Having access to operative and pathology reports increases your chances of correctly coding the patients diagnoses. You can check the surgeons documentation if the anesthesia record has a vague diagnosis or if you need further clarification about the procedure when coding it. This takes longer to complete the process, but our claims are more accurate, Reed says. We also dont get as many denials, because our service codes match the information billed by the surgeon.

Be Sure Everyone Signs It

Anesthesia team members need to sign the patients charge sheet to document their involvement, but initials and signatures should be scattered throughout the chart. Some key places to check for signatures include:

  Notations about induction and emergence: Anesthesiologists who medically direct cases must be present for induction, emergence and other key portions of the procedure. He or she must document this involvement as well as pre- and postoperative care and frequent checks on the patient. An anesthesiologist who personally performs a case simply states this in the record, and everything documented in the case is attributed to him or her.

  Documentation of line placements: Most carriers require that the anesthesiologist place any Swan-Ganz catheters, arterial or CVP lines before they can be reported separately in addition to the procedure. Be sure the documentation clearly shows that the physician personally placed the line and was not simply present at the time the line was placed. Some carriers allow CRNAs to place and bill for lines, so check your local guidelines.
 
The codes for these line insertions are 93503 (Insertion and placement of flow directed catheter [e.g., Swan-Ganz] for monitoring purposes) for Swan-Ganz catheters and 36620 (Arterial catheterization or cannulation for sampling, monitoring or transfusion [separate procedure]; percutaneous) or 36625 ( cutdown) for arterial lines. For lines to monitor central venous pressure (CVP), choose the appropriate code from 36488-36491 (codes related to Placement of central venous catheter [subclavian, jugular, or other vein] [e.g., for central venous pressure, hyperalimentation, hemodialysis, or chemotherapy]), depending on the patients age and the physicians approach.

  Start times, stop times and handoffs: Each record should clearly show which members of the anesthesia team were present at any given time, and his or her involvement with the patients care. This can get especially tricky when multiple team members are involved with a case (either simultaneously or when relieving each other). Reeds group has incorporated multiple start and stop times on their charge capture sheet to make it easier for providers to document their times. Then the coders verify that the times from the charge sheet are actually documented in the medical record. If the times dont match, they pull the original chart so the documentation can be corrected.

Making sure that everyone involved has signed the chart in all the places is one of our biggest documentation challenges, Reed says. The CRNA or resident and physician might have documented their work and signed the chart, but it can be difficult to determine who placed lines or who was present for certain portions (initial assessment, anesthetic course, postanesthesia care) if they dont initial the actual documentation.
 
Editors note: Check next months issue of Anesthesia & Pain Management Coding Alert for more important documentation check-points.