Anesthesia Coding Alert

Necessity, time, and signatures top list of watch points.

Every detail counts when your anesthesia providers place invasive lines that are separately reportable from the standard anesthesia service.

Keep in mind that line placement is a surgical procedure, so the service must be documented before a payer will reimburse.

Avoid denials by training your anesthesia providers to consistently document these five components of line insertion, as recommended by Judith Blaszczyk, RN, CPC, ACS-PM, of Auditing for Compliance and Education in Leawood, Kan.

1. Support Medical Necessity

Because standard anesthesia care includes so many services, documenting medical necessity for additional lines is key. For example, the patient might have coarctation (747.10, Coarctation of aorta [preductal] [postductal]), a narrowing of the aorta between the upper and lower body branches. That type of condition or more common issues such as circulatory problems might also require an additional arterial line for the anesthesiologist's monitoring purposes.

2. Watch the Clock

Your providers should already be accustomed to documenting their start and stop times for any anesthesia case. If they place lines during a case that they expect to bill separately, remind them to document each line's start and stop time individually.

Tip: If your provider places the line intraoperatively, you don't typically need to deduct the placement time from the anesthesia time. If your provider places the lines before anesthesia time starts, however, be sure the case start time is after the line placement time to avoid "double dipping."

3. Pinpoint the Location

The operative note should document where the provider placed the line, such as "right radial artery" or "right intrajugular." The note doesn't make a difference in your code selection, but is good documentation of the line placement.

4. Verify Barrier Method/Technique

If your physicians submit data for PQRS, they should be on the look-out for ways their documentation can support reporting the anesthesia measures. Documenting sterile technique or maximal barrier sterile technique (MSBT) helps support reporting PQRS (Physician Quality Reporting System) measure 76 (Prevention of catheter-related bloodstream infections [CRBSI): Central venous catheter [CVC] insertion protocol).

Measure 76 tracks the percentage of patients who undergo CVC insertion when the provider uses all elements of maximal sterile barrier technique. Requirements dictate that providers use cap, mask, sterile gown, sterile gloves, a large sterile sheet, hand hygiene, and 2 percent chlorhexidine for cutaneous antisepsis.

5. Name the Provider

Even if you have every other detail noted, you'll only be reimbursed when the chart includes the provider's name and signature.

According to MLN Matters (number MM6698 revised), "Definition of a handwritten signature is a mark or sign by an individual on a document to signify knowledge, approval, acceptance, or obligation." This definition was effective March 1, 2010, and was implemented April 16, 2010.

Medicare guidelines allow a handwritten or electronic signature on orders or other medical record documentation for review. Stamped signatures are not acceptable, but the provider can sign her initials over her printed or typed name. (For a handy list of what constitutes an acceptable signature -- and what doesn't -- email the editor at leighd@codinginstitute.com.)

Tip: Keep a signature log and signature attestation statement, advises Catherine Brink, BS, CMM, CPC, CMSCS, president of Healthcare Resource Management, Inc., in Spring Lake, N.J. "This is especially important for Medicare patients," she adds. "In a Medicare audit, they will want to see these to ensure the signature is that of the service provider."

Final note: Documentation is key to compliance and reimbursement because it allows capture of the services provided, Blaszczyk says. "All charges must be substantiated by documentation," she adds. "Remember, if a service isn't documented, from a reimbursement perspective it's the same as not being done."