Anesthesia Coding Alert

Know when the new coding option can help reimbursement

New physician teaching rules went into effect in January, adding yet another piece to the team coding puzzle. Some guidelines haven't changed much, but others have the potential to affect your bottom line. Here's how this Medicare-proposed policy could affect your current claims submission.

Know When Your Coding May Change

Your reporting guidelines don't change when a teaching anesthesiologist works one-on-one with a resident. You should still append modifier -GC (This service has been performed in part by a resident under the direction of a teaching physician) to the claim, and Medicare will pay your anesthesiologist 100 percent of the allowable fee, says Cheryl Pascale, CPC, coder with Hackensack Anesthesiology in Hackensack, N.J.
 
When a teaching anesthesiologist works with three to four residents and/or CRNAs, continue to code these cases as medical direction, using the appropriate modifiers to identify who was involved with the case (modifiers -QK and -GC). Again, Medicare pays the teaching physician 50 percent of the procedure's allowable fee.
 
The possibility of new coding methods applies when a teaching anesthesiologist concurrently supervises two  residents. In these cases, billing depends on whether the anesthesiologist is present with each resident during pre- and postoperative care.
 
"The new rule offers an alternative to billing for medical direction in these cases," says Karin Bierstein, JD, director of governmental affairs (regulatory) for the American Society of Anesthesiologists. "The attending physician must meet the usual requirements for medically directed cases. For the new option, if he can document his presence, he has the choice of billing the full base unit value of the procedure, plus any documented face-to-face time with the patient during surgery."
 
(Under the standard medical-direction formula, the anesthesiologist would receive 50 percent of the base fee, plus the applicable time units.)
 
If the anesthesiologist does not document his presence during the patient's pre- and postoperative care, he can't prove to the carrier that he met the criteria for the new concurrent teaching case option. In this case, assuming he meets the criteria for billing medical direction, the physician receives only 50 percent of the procedure's allowable fee.

Decide Which Reporting Tactic Is Best

The new billing option (full base units plus face time during supervised resident cases) is an alternative to reporting medical direction for concurrent teaching cases, but it's not required, so you should examine your circumstances carefully to determine which method will work best for you.
 
Both options have reimbursement advantages and disadvantages, depending on the case circumstances. Sometimes Medicare will pay more using the new method, but in other cases you'll recoup more pay by coding the case as medical direction. It depends partly on how long the case lasts.
 
This example, based on information from ASA, helps put it in perspective:
 
Suppose your teaching case includes documentation for six base units and 1.5 hours of anesthesia time. The attending physician is also present during the pre- and postanesthesia care, for a total of 40 minutes out of the procedure's 1.5 hours. In this example, coding it under the new option produces 8.7 total units, while medical direction yields only 6 units. Chart 1, shows you how to break down the best option.
 
In longer cases, the medical-direction option may produce more units than the new option, unless the attending physician is present during much of the actual procedure. If anesthesia time during the 6-unit procedure described above doubles to three hours and the attending physician is still present for 40 minutes of that time, the value of the new option doesn't change. But coding it as medical direction yields a total of 6 time units ([12 units x 15 minutes] x 50 percent medical-direction fee). Chart 2, shows how you can calculate the billable units.

 Looking at it this way might tempt you to vary your reporting method on a case-by-case basis. There's nothing wrong with that, but Bierstein says it's often better to decide on a single method and use it consistently to avoid
confusion. "Some anesthesia departments may find it simply unmanageable to report some cases one way and others differently," she says.
 Whichever method you use, it's imperative that you correctly report the physician's time. Remember that anesthesia time starts when the resident or anesthesiologist begins preparing the patient for anesthesia; the time ends when the patient is turned over to the PACU staff.
 The physician should report the actual total minutes that he spent with the resident during the case, but he shouldn't report time spent on the preanesthesia evaluation or postanesthesia care, because those minutes are considered part of the procedure's global (or base) fee.