Anesthesia Coding Alert

Teach your team documentation secrets to get paid consistently

Before you submit a labor epidural claim, you need more than just the correct code--or you risk losing payment for your provider's services. Train your anesthesia team to document the following areas and prepare your claims for smooth sailing.

Key 1: Explain the Services Provided

Reporting a labor epidural begins with CPT's anesthesia codes for labor patients:

- CPT 01967--Neuraxial analgesia/anesthesia for planned vaginal delivery (this includes any repeat subarachnoid needle placement and drug injection and/or any necessary replacement of an epidural catheter during labor)

- +CPT 01968--Anesthesia for cesarean delivery following neuraxial labor analgesia/anesthesia (List separately in addition to code for primary procedure performed)

- +01969--Anesthesia for cesarean hysterectomy following neuraxial labor analgesia/anesthesia (List separately in addition to code for primary procedure performed). But reporting these codes alone isn't enough to satisfy carriers. The anesthesia provider should include other notes on the patient's record to explain the service more fully, make your coding more accurate and meet carrier requirements.

Example: A laboring patient comes to the hospital at 37 6/7 weeks- gestation. If the anesthesiologist notes that the case becomes a cesarean delivery but doesn't explain why, you don't have much documentation to support your claim for 01967 and 01968. Better documentation would include a note such as, -Failure to progress resulted in emergency c-section.-

Having more detailed notes from your providers means you-ll report an associated diagnosis such as 660.6x (Failed trial of labor, unspecified) instead of resorting to a general diagnosis such as 669.7x (Cesarean delivery, without mention of indication).

Key 2: Document Who's Involved

Multiple members of the anesthesia team sometimes become involved with labor patients, especially when cases cross shifts. Cover your coding bases by verifying that the anesthesia record clearly documents:

- Who performed the pre-operative exam

- Who actually inserted the epidural

- Who monitored the patient during labor

- Who removed the catheter following delivery.

The easiest way to document these details is to use a template or some type of check boxes for the providers to mark--but that doesn't mean it's the best way to meet documentation guidelines.

-Anyone can check a box,- points out Kelly Dennis, CPC, ACS-AP, PMCC, owner of the consulting firm Perfect Office Solutions in Leesburg, Fla. -Having the providers- initials or signatures are more clear indications of who was actually involved in the case.-

-The best way to document a service and have proof of it is to write it out and sign it,- advises Barbara Johnson, CPC, MPC, president of Real Code Inc. in Moreno Valley, Calif. -If different physicians are involved in parts of the case (i.e., pre-op, placement and removal), then documentation should show each name/signature and the time he spent with the patient.-

Tip: Some groups use special labor or epidural forms to document these cases. Other groups use a standard anesthesia record to track and monitor patient care and indicate provider involvement.
 
Having clear documentation of which providers participate in a case helps you report the correct performance modifiers for Medicare and other carriers that require them.

Key 3: Check When Monitoring Occurred

Labor can last for hours, which means an anesthesia team member won't just insert the epidural and hover by the patient's bedside until everything is over. Instead, different members of the anesthesia team will be in and out to monitor the patient's progress and the epidural's effectiveness throughout labor and delivery.

Keep these pointers in mind when you-re educating the anesthesia providers about thoroughly documenting labor epidurals:

- How often did someone monitor the patient? Most carriers don't have specific guidelines for an acceptable timeline for labor epidurals, so your group might not need them either. -I-m not sure I would set time limits for this,- Dennis says. -It should depend on the patient's needs.- Examples: A severely pre-eclamptic patient (642.5x, Severe pre-eclampsia) carrying twins needs more monitoring than a healthy patient with an uncomplicated labor (650, Normal delivery). Patient preference also can dictate monitoring because some patients are needy while others prefer minimal interruptions.

- How long was the anesthesiologist with the patient when he stopped by to monitor her? -This is a good way to show whether the anesthesiologist spent an extensive amount of time with the patient,- Dennis explains.

- What happened when the anesthesiologist monitored her? Some carriers (such as New York State Medicaid) expect to find a recorded blood pressure measurement for every five minutes of -face time- with the patient. Other interventions could include -topping off- the epidural, decreasing the epidural level or changing drugs.

Documenting these factors helps you assign the correct time units when you-re coding each anesthesia provider's involvement in the case and when you-re tracking concurrencies for a medically directing anesthesiologist.

Key 4: Modify It Correctly--If It's Needed

If the case you-re coding involves a Medicare patient, complete your claim by including performance modifiers with the delivery code:

- Append modifier AA (Anesthesia services performed personally by anesthesiologist) if a single anesthesiologist handles the case and is not involved with other cases during the same timeframe.

- Report modifier QZ (CRNA service: without medical direction by a physician) if the CRNA provides the anesthesia without physician involvement.

- Use modifier QX (CRNA service: with medical direction by a physician) for a medically-directed CRNA. In this case, be sure to include modifier QY (Medical direction of one certified registered nurse anesthetist [CRNA] by an anesthesiologist) or QK (Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals) on the anesthesiologist's claim for medical direction of the case.

- Submit modifier AD (Medical supervision by a physician: more than four concurrent anesthesia procedures) if a medically-directing physician's load passes four concurrent cases.

Remember: Many commercial carriers (such as Blue Cross and Blue Shield in California) do not accept medical direction modifiers, and some carriers or states do not recognize CRNAs as providers unless they are medically directed. Verify the carrier's guidelines before submitting any of the performance modifiers.