Anesthesia Coding Alert

Question: What are the minimum documentation requirements in order to be compliant with reporting a patient’s anesthesia prep time? Considering CMS’s definition of anesthesia start time as preparing the patient for the anesthesia services, if the anesthesia provider is only performing a review of the patient’s chart, can that be considered compliant for documentation purposes, or should there be other functions or elements to consider besides a review of the patient’s chart? Chapter 12 of the CMS processing manual does not clearly explain this situation. How would this scenario be billed/ considered? Are there any other source documents from other sources that clearly address this topic?

Virginia Subscriber

Answer: According to coding guidelines, anesthesia start time begins when the anesthesiologist begins to prepare the patient for the induction of anesthesia in the operating room (or in an equivalent area). 

Anesthesia end time is when the anesthesiologist is no longer in personal attendance, meaning the patient may be safely placed under postoperative supervision.

These definitions mean that only performing a chart review is not sufficient to code the service. The anesthesia care during the procedure includes the administration of fluids and/or blood and the usual monitoring services (e.g., ECG, temperature, blood pressure, oximetry, capnography, and mass spectrometry). And remember that a few forms of monitoring (e.g., intra-arterial, central venous, and Swan-Ganz line placements) are not included in anesthesia time, so are separately reportable.

Example: Imagine looking at an anesthesia record for a repair of an umbilical hernia, left inguinal hernia, and excision of a right calf mass. The graph across the top of the anesthesia record begins at 7:45 and is timed each 15 minutes (8:00, :15, :30, :45; 9:00, :15, etc). There is activity on the graph beginning with the first block (7:45) and that matches the anesthesia start time (7:45).

The operation prep time is 7:54, incision time is 8:12, and procedure end time is 10:00 a.m. The last activity on the graph also is noted at approximately 10:00 a.m. Anesthesia end time (transfer to PACU) is 10:10.

The documentation supports the anesthesiologist’s start and stop times, which should not include any pre-anesthesia assessment. Note the times before, during, and after surgery and that they should correlate with the documentation.