Anesthesia Coding Alert

Know when – or when not – to code separately for additional services.

Many times, your anesthesia provider – physician, CRNA, or AA – sees a case through from start to finish. Coding can get complicated when multiple providers share a case, especially when one provides additional services. Brush up on some teaching rules with this case submitted by an Anesthesia Coding Alert subscriber.

Scenario: Our attending anesthesiologist started a surgery case. He left after two hours and another attending anesthesiologist took over the case for the remainder of the surgery. The second attending inserted an arterial line. In the past, we’ve billed these situations under the provider who began the case. Now our compliance department says that if a different provider inserts the line, that’s who we should bill it under. Have we been doing this wrong all along? What’s the correct way?

Step 1: Verify Your Group’s General Policy

Some groups bill by the physician who spends the most time on the case. The patient receives only one bill for anesthesia and the compensation is divided between the physicians.

Other groups stick with the guideline that each provider bills each of his or her services. Although this can mean multiple statements for the patient, it also fits the requirements on the back of the CMS-1500 form that states you are submitting a claim and it represents the provider who performed the service.

Step 2: Know the Differences Because of Teaching

“There was a change to the teaching rules a few years ago and teaching facilities are required to report the anesthesia case under the teaching physician who started the case,” says Kelly D. Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Fla. “Any additional procedures – such as the arterial line placement – should be reported under the provider who performed it. So, in this case the compliance department is correct.”

As CMS information states, “Where different teaching anesthesiologists in the anesthesia group are present during the key or critical periods, the performing physicians, for purposes of claims reporting, is the teaching anesthesiologist who started the case.”

Remember: Arterial line placement is considered a surgical procedure instead of part of the procedural anesthesia. Report the appropriate line placement code, such as 36620 (Arterial catheterization or cannulation for sampling, monitoring or transfusion [separate procedure]; percutaneous) under the name of the provider who placed the line. 

“This is especially important as a student registered nurse anesthetist (SRNA) does not receive payment from Medicare,” Dennis points out. “If an SRNA places a line, the teaching physician or CRNA must be hands-on for the procedure to be billed under the name of the provider number for the physician or CRNA. If Medicare requests documentation and sees that a SRNA placed the line without assistance, it is not considered for payment.”

Step 3: Watch Who Placed the Line

Dennis says another important issue to remember is that if a student nurse performs the procedure without a teaching physician or CRNA being “hands on” – the service isn’t billable.

“Medicare will deny payment for an arterial line when the only person documented as providing the procedure was an RN,” Dennis explains.

Reasoning: This CMS stance likely comes from CR 6706: “… the payment policy for the teaching CRNA in the single student nurse anesthetist case remains unchanged for services furnished on or after January 1, 2010; however, under MIPPA Section 139, when involved with two concurrent cases with student nurse anesthetists (on or after this date), he or she can be paid at the regular fee schedule rate for each case. To bill the base units for each of the two cases, the teaching CRNA must be present with the student during the pre and post anesthesia care for each case. In addition, while he or she can decide how to allocate time to optimize patient care in the two cases based on the complexity of the anesthesia case, the experience and skills of the student nurse anesthetist, the patient’s health status and other factors; the CRNA must continue to devote all of his or her time to the two concurrent student nurse anesthetist cases and not be involved in other anesthesia cases. The teaching CRNA may bill usual anesthesia time for each anesthesia case. For services furnished on or after January 1, 2010, the teaching CRNA should report these cases with the QZ modifier as described above. You should also remember that the teaching CRNA’s medical record documentation in these cases must be sufficient to support the payment of the fee and be available for review upon request. Additionally, be aware that no payment is made under Part B for the service provided by a student nurse anesthetist.”

Final point: “The required teaching documentation should be clear to anyone reviewing the record – whether electronic or paper,” Dennis says. “Signatures alone do not indicate who did what, especially with ancillary services such as arterial line placement. Have the notes to back up your claim.”