Anesthesia Coding Alert

Question: I’m brand new to anesthesia coding. When does anesthesia time start and stop?

Nevada Subscriber

Answer: Anesthesia time starts when the anesthesia provider assumes control of the patient’s care for the procedure being performed. Typically, anesthesia time starts at the time the patient enters the operating room and the anesthesia provider is in constant physical attendance with the patient. If your provider is delayed and enters the OR later than the patient, the start time begins when the provider enters the OR.

Anesthesia time stops when your provider is no longer caring for the patient and has transferred that care to another person (i.e., the PACU staff). This time usually is when the anesthesia provider leaves the patient’s bedside in PACU. Typically, anesthesia stop time is within 10-15 minutes of the surgical stop time. If this time is longer, there should be a reason cited in the record such as “extra time spent with patient managing laryngospasm.”

Remember: Pre-op and post-op visits are standard parts of anesthesia service and are included in the base units for each anesthesia code. Therefore, don’t bill for time spent talking to the patient in the pre-op area.

Exception: If the patient has a severe anxiety disorder, requires a much larger than average pre-operative sedative, and is personally escorted to the OR by your provider so the patient’s status can be monitored during the transport, then you could start the anesthesia time at the time your provider administered the sedative. Again, this should be well documented in your record and is a rare occurrence.