Anesthesia Coding Alert

Know whether extra services help or hurt your claim

Your anesthesiologist is medically directing three cases when he's asked to step out and assist with a service for another patient. Is he still able to report the initial cases as medically directed? Here's how to decide.

Count These 'Extra Services' Toward Medical Direction - if They're Quick

Determining whether cases can be coded as medically directed is challenging for almost every coder. Some coders blame the vague terms CMS chose for its seven rules for reporting medical direction (see "Coding Supervision Changes Your Fee" in a later section of this article for a list of these criteria).

HCFA muddied the waters even more by stating that the medically directing anesthesiologist may perform other duties concurrently (sometimes known as the "Six permissible sins" of medical direction). These duties include:
 

Addressing an emergency of short duration in the immediate area
 

Administering an epidural or caudal anesthetic to a patient in labor
 

Performing periodic, rather than continuous, monitoring of an obstetrical patient
 

Receiving patients entering the operating suite for the next surgery
 

Checking or discharging patients in the PACU
 

Coordinating scheduling matters.

One of the most common questions regarding these "exceptions" is: What constitutes an emergency of short duration? Specific answers might vary from one coder to the next, but the consensus is usually the same: It's a judgment call.

"Each practice must decide on its own how to interpret 'short duration,' " says Denise Giliberti, CPC, practice manager for NM Anesthesia Associates PC in New Milford, Conn. "It depends on the size of the facility in which you work. Can a physician who is helping in the ED or ICU of a large hospital really get back to the OR quickly enough? In our hospital, the ICU is across the hall. In some larger hospitals, it is in another wing. It really comes down to a decision the group must make."

Documentation Can Help Support 'Short Duration'

Some services are fairly easy to justify as emergencies of short duration, which means you shouldn't have trouble with reimbursement. Donna Howe, CPC, of Anesthesiology Associates of Eastern Connecticut in Manchester says the most common examples in her group are intubation for adults in respiratory arrest and for infants with meconium (31500, Intubation, endotracheal, emergency procedure).

Other examples include treating nearby PACU patients with problems such as hypotension (458.x, Hypotension), respiratory distress (786.09, Dyspnea and respiratory abnormalities, other; 518.82, Other pulmonary insufficiency, not elsewhere classified; or 518.5, Pulmonary insufficiency following trauma and surgery) or inadequate pain medications.

"There's generally a written report, but we rarely have to send a copy to the carriers," Howe says. "When we code a diagnosis such as respiratory arrest or meconium, there is little doubt as to the emergency status.

"However, defining the situation isn't always so easy. One challenge can be helping educate your physicians that services are accepted as emergencies of short duration while other services that seem similar might not be.
 
Example: The guidelines state that the physician can administer an epidural or caudal anesthetic to a patient in labor while medically directing several cases. Coders such as Giliberti say their physicians have a hard time realizing that an epidural steroid injection (ESI) - which usually takes less time than a laboring epidural - does not constitute "short duration."

The difference in the two epidural situations is that the ESI is an elective procedure the physician can administer at any time; a laboring epidural cannot be delayed until a three-hour case is finished. (CPT includes many codes for ESIs, depending on the circumstances. Common ones include 62310, Injection, single [not via indwelling catheter], not including neurolytic substances, with or without contrast [for either localization or epidurography], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or subarachnoid; cervical or thoracic; 62311, ... lumbar, sacral [caudal]; 64479-64484, various sites for Injection, anesthetic agent and/or steroid, transforaminal epidural.)

Consider Setting a Definition of 'Short Duration'

Neither Giliberti nor Howe has ever seen anything in writing that defines "short duration."

"I've never seen anything official in writing and doubt if it exists," Howe says. "I'm not sure 'short duration' can be measured in minutes, or maybe CMS would have defined it (which is what everyone is looking for). I think there has to be a common-sense approach."

If you're attempting to define "short duration" for your group, consider these perspectives from Howe, Giliberti and other coders on the Anesthesia & Pain Management Coding Alert listserv:  

The service should take no more than a minute or two for the anesthesiologist to reach the patient.
 

The service should be no longer than the amount of time the patient could survive without oxygen.
 

Remember that in anesthesia, an "emergency" is defined as a threat to the patient's life or limb.

Because there's not an official definition or set of parameters for "short duration," some coders believe you should address it yourself. Opinions on whether that's good or bad vary.

Pros: One obvious positive aspect of creating your own definition is that everyone in your group should be on the same page in terms of following the guidelines. Supporters also believe the guidelines could come in handy during an audit. If questions regarding "short duration" come up, you can point to your group's policy and explain that you've developed your own definition or criteria since an official, clear definition does not exist.

Cons: "Once you have a written policy, you have to be sure you adhere to that policy exactly," Howe says. "I agree that each practice should develop its own definition, but coders aren't always sure the policy must be in writing. You should also consider that carriers might not agree with your rule and that, if you deviate from it in any way, you broke medical direction based on your own policy."

"Each practice must decide on its own how to interpret this," Giliberti adds. "It's hard to break a rule that hasn't been defined."

Coding Supervision Changes Your Fee

Many anesthesiologists prefer to work on cases that qualify as personally performed (which you report withmodifier AA, Anesthesia services performed personally by anesthesiologist) or medically directed (which you report with either modifier QY, Medical direction of one certified registered nurse anesthetist [CRNA] by an anesthesiologist, or modifier QK, Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals). Personally performing or directing cases means he can provide more focused care, but an added bonus is it also helps his bottom line.

The first guideline for medical direction is that the anesthesiologist must be directing four or fewer concurrent cases. Then he must also meet CMS' seven rules for medical direction:

1. Perform preoperative exam and evaluation.
2. Prescribe the anesthesia plan.
3. Personally participate in the most demanding procedures of the anesthesia plan, including induction and emergence.
4. Ensure that any procedures in the anesthesia plan are performed by a qualified anesthetist.
5. Monitor - and document - the course of the anesthesia administration at frequent intervals.
6. Be physically present and available for immediate diagnosis and treatment of emergencies.
7. Provide the postanesthesia care indicated.

If the anesthesiologist fails to meet any of these criteria (or if the case load climbs to five concurrent cases), you must report the cases as medically supervised (by append-ing modifier AD, Medical supervision by a physician: more than four concurrent anesthesia procedures) instead of medically directed. Sometimes shifting gears from medical direction to medical supervision can't be helped, but practices try to avoid it for a combination of reasons. One of the main reasons involves the bottom line because you can see a big difference in reimbursement for supervision versus direction.

With medical supervision cases, the physician can only bill for 3 base units and no time, Giliberti says. The CRNA involved with the case can bill for the actual base units and time units, but is only paid at 50 percent, according to medical-direction rules.

"If your state, practice and hospital allow it, you would do better to bill a QZ (CRNA service: without medical direction by a physician) for the CRNA working alone," Giliberti says. "This way the CRNA will be paid at 100 percent for the case."

Example 1: If your group provides anesthesia for a two-hour spinal procedure with instrumentation, this is how you would be paid if your fee is $50 per unit (15-minute units, for a total of 8 time units):

Supervision MD $150    CRNA $525        Total $675

CRNA alone $1,050

"We rarely have situations that require modifier AD, so it has a minimal impact on our bottom line in general,"  Howe says. "However, it can have a large impact on individual cases."

Example 2: If an anesthesiologist medically directs a case with a high number of base units (such as 00406, Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; radical or modified radical procedure on breast with an internal mammary node dissection, which is 13 units) and the service becomes medical supervision, the anesthesiologist can only be reimbursed for 3 base units (or 4 units if his participation in induction is documented). This is a loss of 9 or 10 units on a single case.
 
"At the Medicare reimbursement rate, it is a discount of less than $200, but obviously if it were to happen often it would add up rather quickly," Howe says.

Knowing whether to bill your anesthesiologist's cases as medically directed or supervised can be quite tricky,  especially because medical-direction guidelines are chock full of "gray areas." But by working with your physicians and carriers to understand terms such as "an emergency of short duration," you can be sure your claims - and your reimbursement - are accurate.