Anesthesia Coding Alert

Keeping accurate patient records takes time and a lot of attention to detail. Here are a few things auditors want to see in anesthesia records, according to Dennis and LeGrand:

 

Documentation of details. Was the physician or CRNA always present for any segments billed as face-to-face time? Are "to" and "from" times recorded accurately? Are induction and emergence (except in MAC cases) documented correctly? Do the records show who placed individual lines? Are times recorded in exact minutes rather than rounded to the closest five-minute increment?

Certain procedures, such as an endarterectomy (+33572, Coronary endarterectomy, open, any method, of left anterior descending, circumflex, or right coronary artery performed in conjunction with coronary artery bypass graft procedure, each vessel [list separately in addition to primary procedure]; and 33916, Pulmonary endarterectomy, with or without embolectomy, with cardiopulmonary bypass), require additional monitoring, and extra details in the patient's record can help justify higher reimbursement.

Correct use of physical-status modifiers (P1-P6, found in the front of CPT anesthesia section) for the patient and supporting diagnoses to justify the higher codes' usage.

Appropriate bundling. Providers shouldn't bill separately for services that are bundled into the global anesthesia fee, such as fiberoptic intubation, or standard monitoring services such as pulse oximetry, ECG, blood pressure or capnography.

Accurate diagnosis and procedure codes that reflect what is in the actual record and that are the highest level of specificity.

Legible handwriting and appropriate signatures for the anesthesia providers.

Few high-level E/M codes. Frequent use of high-level E/M codes can raise red flags to auditors, such as 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed history; a detailed examination; medical decision making of moderate complexity), 99215 ( a comprehensive history; a comprehensive examination; medical decision making of high complexity) or 99223 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity). Medicare and other carriers want to see a range of E/M codes reported, but with most in the middle.

Accurate coding of services based on documentation in the patient's record, rather than overcoding or undercoding for services.