Anesthesia Coding Alert

Anesthesia for most procedures is charged based on the number of base units for the procedure plus the amount of time spent on it. However, different guidelines apply to obstetrical (ob) anesthesia, depending on the provider, the carrier and the situation. As a follow-up to last month's article (page 9) on the new ob anesthesia codes (01960-+01969) for 2002, we now examine the methods for billing the time for labor epidurals and the benefits and flaws of each.
 
In October 2000, the American Society of Anesthesiologists (ASA) published a list of recommended methods for billing anesthesia, acknowledging that different ones may work better for different practitioners. The group sanctioned four:

 1. base units plus time units (insertion through delivery), subject to a reasonable cap

 2. base units plus patient contact time (insertion, management of adverse events,    delivery, removal) plus one unit hourly

 3. single fee

 4. incremental fees (e.g., zero-two hours, two-six hours, less than six hours).

Some practices also use two other methods of billing for time 5. base units plus time units with no cap, and 6. base units plus face-to-face time with the patient. Based on individual circumstances and contract negotiations, carriers may accept any of these six methods.
 
Providers, even within a single group, vary considerably on which method they use. Many providers use more than one method, depending on the carrier.

Charging for base units plus time, with a cap limiting the time, has been the most popular billing method for ob anesthesia. Although reimbursement may not always be higher than with other methods, it is easy to compute and helps claims get processed easily, says Kelly Dennis, CPC, EFPM, of Perfect Office Solutions in Leesburg and president of the Florida Anesthesia Administrators Association. However, it can be more difficult to justify from a compliance standpoint because face-to-face time with the patient isn't documented.
 
A key part of this formula is the definition of a "reasonable" cap for the amount of time being billed and, as Dennis points out, "reasonable" is in the eye of the beholder. Because the ASA has determined that the average labor lasts for four hours, physicians who cap their time in this vicinity are likely to be reimbursed without many questions. But the risk of not receiving reimbursement increases for physicians who set their cap at a higher level.
 
"The physician group is responsible for setting its own fees, but they may have contracted amounts with different carriers," Dennis says. "The fees are usually negotiable, so you may want to negotiate in advance for additional consideration in atypical cases, such as those that last longer. If, however, you have capped your fee or agreed to a contracted amount, you often do not get extra reimbursement for difficult or atypical cases, even with supporting documentation.
 
"We found most carriers receptive to this system," Dennis continues. "The good thing about it is that you're able to set a fair standard fee that is consistent, regardless of carrier, and patients know in advance what costs are involved. The drawback is that when you establish a cap you're limiting your maximum reimbursement because some carriers still pay full fee."
 
That drawback leads to a variation of this method billing the base units plus time, but without a cap on the amount of time. The anesthesiologist receives good reimbursement with this process, but not many practitioners report their ob services this way, possibly because it's often viewed as less fair than the other methods. For example, if the anesthesiologist charges without a cap and the case is lengthy, the charge for anesthesia could turn out to be higher than the obstetrician's.

Recent surveys of anesthesia professionals show this as the second most common reporting method for ob services. This formula may result in lower physician fees than some of the other options, but documentation in the patient's medical record often supports it, and carriers seem to reimburse the fees without question. Even if there is no face-to-face time in an hour, an anesthesiologist must be readily available to respond to any emergency or other situation(s) once the labor epidural has been inserted. This formula is seen as fair because the anesthesiologist should be compensated for that availability even if he or she does not see the patient during the hour.
 
"It's my understanding that the one unit hourly is charged as standby time (99360, Physician standby service, requiring prolonged physician attendance, each 30 minutes [e.g., operative standby, standby for frozen section, for cesarean/high risk delivery, for monitoring EEG]), and any actual patient contact is charged as such," says Donna Howe of the physician group Anesthesiology Associates of Eastern Connecticut in Manchester. "It seems to me that in the event of a difficult case the patient contact time would probably increase and there would be a lower hourly charge for the anesthesiologist.
 
"It's good that with this method the physician gets some reimbursement for being available," Howe says. However, during a difficult case that might involve more face-to-face contact, tracking can be difficult. "I assume you wouldn't charge for both times during the same hour, but it gets complicated."
 
For example, if a labor epidural is inserted at 12:01 a.m. (taking about one-half hour) and the delivery is at 6 a.m., confusion arises as to whether you begin counting the extra units per hour at 12:31 a.m. or from the beginning, and if you add the face-to-face time units with the extra standby units and adjust them to arrive at a stop time that equals the total number of time units the physician wants to bill. Most physicians start counting the one-unit charge per hour from insertion time, but this can vary. Ask the physicians you bill for when they begin counting the extra-hour unit.

Because some carriers pay a flat fee for ob anesthesia, some physicians charge that fee for their services. Although it may sometimes work, many billers advise against this method.
 
Carriers are used to paying anesthesiologists according to base units and time. When they see claims from anesthesiologists that don't include fees for time, they may question the claims.
 
But Dennis, whose group had a flat-rate agreement with Blue Shield Health Options and SunHealth, says that flat-fee billing can work well in some instances. "We didn't run into any problems with the carriers being confused about only one code being reported. Some carriers require the procedural CPT codes instead of anesthesia codes anyway, so they may not notice much difference. In our case, the physicians still billed their normal amount for services but received the contracted amount as reimbursement. Sometimes they received more than if they'd used another billing method, sometimes less, depending on the case."

4. Using Incremental Fees

Some physicians establish their labor epidural fees based on increments of time. The group sets its own fees according to the base fee amount (which can vary, based on the local market) plus the approximate number of time units for different increments. For example, if the physician follows the ASA's example of increments, this could mean fees such as:

 

 $750 for two hours or less
 

 $1,000 for cases lasting two-six hours
 

 $1,500 for cases lasting more than six hours.

Although these time spans may seem too great, practitioners believe everything balances out in the end. The anesthesiologist would charge the same amount for a two-hour, five-minute labor as for a five-hour, 45-minute labor. The shorter cases where it seems like reimbursement may be too high help compensate for the longer cases where reimbursement may seem too low.

The safest or most conservative formula is to report the procedure's base units plus documented face-to-face time with the patient. This decreases physician reimbursement, which is probably why only a few physicians use this method.
 
"This is not necessarily the best method to use in regard to reimbursement, but it's what we do," Howe says. "It's really easy to bill. We have one carrier who wants us to charge base plus insertion time (01960, Anesthesia for; vaginal delivery only) then additional contact billed with 01996 (Daily management of epidural or subarachnoid drug administration). But most carriers just want the total number of base plus time units."
 
Note: Although the carrier Howe describes wants additional contact billed with 01996, other insurers may reject this because it is not a labor analgesic code.

Providing anesthesia for an ob patient after hours or on the weekend does not constitute an emergency. Code +99140 (Anesthesia complicated by emergency conditions [specify] [list separately in addition to code for primary anesthesia procedure]) is inappropriate for most of these situations.
 
The ASA Relative Value Guide defines an emergency as "existing when delay in treatment of the patient would lead to a significant increase in the threat to life or body part." Although a woman may go into labor when she has a full stomach, and having stomach contents can represent an increased risk and a potential emergency, that doesn't mean that starting her labor epidural qualifies as an emergency.
 
When a threat exists for mother or baby, a charge for emergency units is appropriate. "The only time we would use an emergency code is if the patient had a true emergency such as fetal distress or had to have an emergency cesarean section," Dennis adds. "But if the physician properly documents the file and uses the correct ICD-9 codes to justify an emergency, being reimbursed for the emergency code [which Howe's group bills as a separate line item] shouldn't be a problem."

Having several options gives a practice the flexibility to change what doesn't work. If you switch camps periodically to see what works best, focus on one system at a time so patients and carriers are treated equally and you aren't perceived as just trying to get the most reimbursement you can. It's also easier to code if you use the same method for all carriers.