Part B Insider (Multispecialty) Coding Alert
You Could Be Throwing Away Hundreds Of Dollars With Incomplete Reports
Some anesthesiologists use surgical reports instead of their own
As everybody knows, anesthesia begins some time before and ends well after a surgical procedure. But anesthesiologists don't always get credit for that extra time.
Some anesthesiologists want to bill based on the surgical log, which only notes the start and end time of surgery, complains Christina Olson, consultant and auditor with South Oakland Services in Warren, MI. Oftentimes, these doctors practice out of hospitals and then have a side job at a surgery center or eye care clinic and "because it's not their regular full practice, they want to cut corners," Olson laments.
Other providers will only list what they planned to do, not what they actually did, Olson adds. Or they'll write down the times that they began and ended anesthesia, but they won't sign the report or record any other information about the procedure.
Important: Anesthesia can take anywhere from 10 minutes to half an hour longer than surgery, notes Olson, depending on co-morbidities and the patient's level of illness. So if you code from the operative report instead of from an anesthesia report, the anesthesiologist could be missing out on $60 to $70 per patient.
Snag: But the carrier might deny the claim altogether for lack of documentation, notes Lee Broadston, president and CEO of BCS in Waconia, MN. If a carrier audits your claims and you don't have an anesthesia record to back you up, then it's not even worth appealing the denial, Broadston says. The anesthesia record is "the only way to support the service being performed."
If a patient or someone else decides to sue, you won't have any record that the anesthesiologist checked the machines, not to mention details of dosages, Olson points out.
Tip: In addition to stop and start time, the anesthesia report should mention co-morbidities and whether the patient had any "P factors," which might also increase the number of units billed, notes Pat Larabee with InterMed in South Portland, ME.
Part B Insider (Multispecialty) Coding Alert
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