Anesthesia Coding Alert

Figure out what qualifies as “emergency.” 

“Emergency of short duration” is among the criteria for extra services your anesthesiologists can perform when their claim qualifies for medical direction. Read on to know which situations could satisfy the “emergency criteria” for these cases – and earn your anesthesiologist full pay for his services. 

Understand the Definition of ‘Emergency’

Last month’s issue of Anesthesia Coding Alert (Vol. 16, N. 8) gave insight to the criteria of ‘‘short duration.” What fits into the slot of “emergency,” however, has yet to be clarified by CMS or other payers.CPT® 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.”

“This exception is often used in cases of trauma or injuries,” says Kelly Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Fla. “When cases are on the OR schedule, they are not often emergencies.” 

Remember What CMS Says About Medical Direction

“Medical direction” is the term for situations when an anesthesiologist oversees two, three, or four concurrent anesthesia procedures involving other qualified individuals. You append modifier QK to the claim to indicate medical direction. 

Normally, an anesthesiologist should not render additional services to other patients while he or she medically directs the administration of anesthesia by a CRNA or other qualified professional. 

However, CMS outlines a few “permissible sins,” or services that are allowed during medical direction (as long as the services don’t affect his ability to medically direct the concurrent cases). 

These permitted situations are: 

• Addressing an emergency of short duration in the immediate area.
• Administering an epidural or caudal anesthetic to ease labor pain.
• Periodic rather than continuous monitoring of an obstetrical patient.
• Receiving patients entering the operating suite for the next surgery.
• Checking on or discharging patients from the post anesthesia care unit.
• Coordinating scheduling matters.

Justify Your Diagnosis Codes

Some services are fairly easy to justify as emergencies of short duration, which means you shouldn’t have trouble with reimbursement. 

Two common examples can include intubation for adults in respiratory arrest and for infants with meconium (31500, Intubation, endotracheal, emergency procedure). 

Other examples related to the patient’s diagnosis include treating nearby PACU (post-anesthesia care unit) 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. 

Hidden benefit: When you include these types of diagnoses on the anesthesia claim, insurers will often agree that it was an emergency situation and won’t give you trouble with reimbursement or asking for other documentation. 

Watch for other opportunities: What about duties that are similar to the “permissible sins” but not exactly the same? Do they count as acceptable activities during medical direction? 

For example, an anesthesiologist might place an epidural block right in the operating room (OR) suite for pain management. It doesn’t take as long to do that as to place a labor epidural (00857, Neuraxial analgesia/anesthesia for labor ending in a cesarean delivery [includes any repeat subarachnoid needle placement and drug injection and/or any necessary replacement of an epidural catheter during labor] or 00955, Neuraxial analgesia/anesthesia for labor ending in a vaginal delivery [includes any repeat subarachnoid needle placement and drug injection and/or any necessary replacement of an epidural catheter during labor]). Because of this, some coders believe the service should qualify as a “permissible sin.” 

Your best approach is to verify that you have clear documentation of the services and the time involved, then talk with the payer before filing your claim. 

Tip: Dennis advises coders to check for Frequently Asked Questions (FAQs) from their Medicare Administrative Contractor about medical direction. “There are a number of these floating around,” she says. “Some payers have specific allowable services that go beyond the six permissible services. 

Keep This Caveat in Mind

If the emergency case took more of the anesthesiologist’s time and he is not available to the medically directed CRNAs (meaning he has to leave the immediate area/OR), he can no longer be considered as medically directing the CRNAs. He cannot bill for any of his involvement in those cases. Submit the claims for the CRNAs with modifier QZ (CRNA service: without medical direction by a physician).

CMS agrees that the duties listed above [meaning the 6 permissible sins] are reasonable, consistent with sound medical practice, and would not cause the medically directing anesthesiologist to be in violation of CMS rules for medical direction. At least that’s the case as long as the medically directing anesthesiologist remains physically present and instantly available for immediate diagnosis and treatment of emergencies (one of the seven medical direction criteria).

Bottom line: The rules are ambiguous, but you don’t want your group to try to stretch the limits. If you play it safe and follow the concurrency guidelines to the “T”, you won’t run the risk of appearing to look even remotely fraudulent.