Anesthesia Coding Alert

Clarify 'present and immediately available' up front to help your medical-direction claims

The size of your hospital's surgery department or the location of labor and delivery won't change your codes for procedures, but they can change the anesthesiologist's performance modifier--and his reimbursement.

You consider these types of factors when you-re deciding whether to report medical direction or medical supervision for the anesthesiologist's service, says Eileen Lorenco, RHIT, CS, CPC, coding manger with Lahey Clinic in Burlington, Mass. Anesthesiologists routinely step out from medically directed cases to perform other allowable services (such as starting a patient's labor epidural), so you need to be sure he's still -physically present and immediately available- under medical-direction guidelines before you code it as such.

Know How the Factors Affect Coding

If the anesthesiologist personally performs a case, you know where he is for the entire procedure and report modifier AA (Anesthesia services performed personally by anesthesiologist) with the procedure code (for Medicare cases or commercial carriers that follow Medicare rules). The carrier pays him for the entire case.

Break it down: Coding gets trickier when the anesthesiologist oversees other members of the team rather than personally performs cases. If he medically directs one CRNA, report modifier QY (Medical direction of one certified registered nurse anesthetist [CRNA] by an anesthesiologist) with the procedure code; if he directs from two to four anesthetists, report modifier QK instead (Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals). Physicians who medically direct cases split the procedure fee with the other anesthetist(s) involved.

Remember: Cases don't qualify for medical-direction reporting simply because the anesthesiologist oversees a certain number of procedures. He must also meet all seven of CMS- medical-direction criteria, listed in the box later in this issue.

If the anesthesiologist does not meet all seven criteria for medical direction (or if the case load goes over four concurrent cases), you must report all of the cases as medically supervised (by appending modifier AD, Medical supervision by a physician: more than four concurrent anesthesia procedures) instead of medically directed. This shift in codes means changes to the physician's bottom line because he can only bill for three base units (and no time units) for medically supervised cases. That's a big difference from payment for personally performed or medically directed cases.

Note: If the anesthesiologist does not meet medical-direction criteria, the CRNA might be able to report the case as nonmedically directed (with QZ, CRNA service: without medical direction by a physician). Know the hospital's policies before coding this way because many only credential CRNAs to work in conjunction with anesthesiologists.

Consider Individual Circumstances

-I think Medicare made the term -immediately available- in the guidelines purposely vague to take into consideration that each anesthesia practice will have a different physical layout, and that might affect their policy,- Lorenco says.

But accurately defining -immediately available- is more than looking at the hospital's blueprints. It also takes each situation into account. Example: The anesthesiologist needs to be more readily available to help during an emergency when he's directing an aneurysm repair rather than a hernia repair.

Consider these three factors when trying to determine what qualifies as -physically present and immediately available- in your hospital: 

- OR size: The number of surgery suites can help determine whether the anesthesiologist is immediately available if he's in another part of the OR. -There's a difference in a location that can be reached in under three minutes versus a location that is 10 minutes away,- says Tammy Reed, senior billing manager for the department of anesthesiology at Oklahoma University Health Science Center.

Example 1: Staying within a small surgery department probably means you can code the case as medically directed. It can be more difficult for an anesthesiologist in the far reaches of a 30-suite OR to be immediately available for medically directed cases (depending on the circumstances).

- Service location: Anesthesiologists are found all over the hospital these days, whether it's in the main OR, outpatient services, radiology, labor and delivery, or trauma and step-down units. Pay close attention to where your physicians are providing services because they might be spreading themselves too thin to still qualify as immediately available.

Example 2: Quickly checking on a patient in the adjacent department could meet the medical-direction criteria. The further the anesthesiologist is from the OR, the tougher it is to document--and prove--he's still immediately available.

- Patient condition: Most anesthesiologists typically have hands-on involvement with more complicated cases, whether because of the procedure being performed (such as anesthesia during coronary artery bypass procedures [00562, Anesthesia for procedures on heart, pericardial sac, and great vessels of chest; with pump oxygenator]) or because of the patient's health (such as a patient qualifying for P4, Patient with severe systemic disease that is a constant threat to life, due to unstable angina, 411.1, Intermediate coronary syndrome).

Anytime an anesthesiologist medically directs, he must be available to take over a case immediately if the anesthetist isn't sure how to handle a patient's unanticipated response.

Example 3: The patient suddenly becomes hypotensive during the procedure. The anesthesiologist determines how to treat the problem and provides the care.

Put It Into Practice

-Each anesthesia practice must set its own guidelines for what it considers -immediately available,- - Lorenco says. -Then this definition must be written into a policy and kept in the department.-

Compliance key: But everyone in the group must follow the policy once it is in place. -Physicians need a common definition or they-ll interpret it differently,- says Judith Semo, a Washington, D.C., attorney who specializes in working with anesthesiologists and anesthesia groups on practice management issues. -Once you write a policy, they must follow it.- Why? Because not following the guidelines is worse than not having it in writing in the first place.

-My suggestion is to discuss this with your local carrier,- Reed adds. -Give them an outline of the setup and the situations that might arise, and get their interpretation for your specific scenario.-

Experts weigh in: When you-re ready to write your group's guidelines for -immediately available,- consider these opinions from our experts:

- Location is key: If the anesthesiologist goes to start a patient's labor epidural, he could still be -immediately available- if labor and delivery is adjacent to the OR (which means you can report modifier QY or QK for the medically directed case, depending on the situation). But if labor and delivery (or any other department the anesthesiologist provides services in) is on another floor or in another wing, be much more careful about reporting it as part of medical direction.
 
- Returning time: If a medically directing anesthesiologist leaves the OR, he should be able to return quickly if he's needed. Lorenco says if she made the policy, she would want the physician to be available in less than one minute to comply with -immediately available.- If it takes longer than that, you might have to resort to coding the case as medically supervised instead (with modifier AD).

- Coding view: Look at your definition of -immediately available- from an auditor's viewpoint. Being less than one minute away in another OR suite is much more believable--and easier to support with documentation--than being in another department.

-Hospitals are asking anesthesiologists to do more all the time, in more parts of the hospital,- Semo says. -Anesthesiologists are more comfortable doing more now than they were years ago when the guidelines were first set because of different anesthetic agents and better monitoring techniques.-

Semo adds that these advances in practice don't change medical-direction requirements. Because of this, you need to keep up-to-speed with how your physicians- services mesh with the medical-direction criteria.

Checkup time: Always update your policy when there's a change in the services your anesthesiologists provide--or a change in the location of these services. Even if nothing substantial changes, revisit your policy annually to tweak or revise it as necessary.