May 2019

Coding Corner: Anesthesia Coding: Tips to Maintain Accuracy
By Weaver Hickerson
For The Record
Vol. 31 No. 5 P. 26

The mandate for reliable health care data is more crucial than ever. As part of that effort, the coding process, which plays a critical role in ensuring data completeness, accuracy, and trust, is garnering the attention of revenue leaders. While accurate coding depends on multiple factors, it all begins with maintaining standards of compliance and integrity. Coding rules, payer policies, documentation requirements, and regulations are paramount.

Due to the complexity of its documentation, correct anesthesia coding takes these mandates a step further with additional challenges. However, there are steps available that can make life easier for coding directors, managers, and staff tasked with ensuring the integrity of anesthesia data.

Six Common Challenges
The difficulties with properly documenting anesthesia magnify its coding challenges. Physicians are required to keep an accurate report of the time and document all procedures performed while the patient is under anesthesia. Specific protocols exist for every stage of anesthesia treatment.

The following are common complexities in anesthesia documentation:

• lack of access to anesthesia records, operative reports, and other hospital-based patient information;
• delineation of anesthesia time;
• specification of medical direction vs medical supervision;
• compliance with the seven steps of medical direction;
• careful monitoring of overlapping cases by a single anesthesiologist; and
• varying rules when residents are involved in the case.

Without timely access to compliant documentation, the anesthesia practice’s coders are left in the dark, improper codes are assigned, and claims are denied.

For example, reporting time correctly can befuddle even the most conscientious practices. Anesthesia time starts when the anesthesia provider begins preparing the patient for anesthesia and stops when the patient no longer needs the personal attendance of the anesthesia provider.

Reporting anesthesia time incorrectly can lead to a loss in revenue and even fraudulent claims. To achieve integrity in anesthesia coding, coders should focus on three specific areas: compliance with the seven steps of medical direction, adding the correct modifiers, and securing access to complete anesthesia documentation.

The Seven Steps of Medical Direction
Medical direction occurs when an anesthesiologist is involved in directing the anesthesia care provided by a certified registered nurse anesthetist or a physician’s assistant trained in anesthesia. The anesthesiologist may direct multiple, concurrent anesthesia procedures.

Medical direction is permissible and fully reimbursable for up to four concurrent cases. However, if the anesthesiologist overlaps more than four cases—for even a minute—treatment is considered medical supervision and reimbursement is reduced for all of the concurrent cases.

According to Leslie Dennis, owner of Stateside Medical Solutions, successful coding of medical direction relies on compliance with the seven elements agreed upon by both the American Society of Anesthesiologists and Medicare. Although most coders and anesthesia professionals know the seven steps of medical direction, frequent review by anesthesia coders is warranted to ensure accurate documentation.

Physicians must document they completed each of the following medical direction functions:

• perform a preanesthesia exam and evaluation;

• prescribe an anesthesia plan;

• personally participate in the most demanding procedures in the anesthesia plan, including induction and emergence (where applicable);

• ensure a qualified individual performs any procedures in the anesthesia plan that the anesthesiologist does not personally perform;

• monitor the course of anesthesia administration at frequent intervals;

• remain physically present for all critical portions of the procedure and be available for immediate diagnosis and treatment of emergencies; and

• provide postanesthesia care as indicated.

If the payer discovers inadequate medical direction documentation during claim review or retrospective audit, the anesthesia practice must reimburse the difference or incur take-backs from future reimbursements.

Modifier Use
Another important area for coders to understand is the proper use of anesthesia modifiers. A modifier is a binary alpha or numeric code added to clarify billed services.

According to Dennis, “Modifiers attached to anesthesia codes inform payers what happened medically for each case.” Modifiers, which are payment driven by payer, vary based on provider type.

Modifiers help eliminate the appearance of duplicate billing. For every anesthesia procedure billed, coders are required to use basic modifiers to identify specific situations, which increases accuracy in reimbursement and consistency in coding.

(For more examples of proper and improper use of anesthesia modifiers, refer to the American Medical Association tool on coding resources.)

Gain Access to Anesthesia Documentation
Underlying all correct coding and billing is clear documentation. “Many practices code just from the anesthesia report, but you can code better and improve reimbursement if you view all the documents,” says Richard Posey, vice president of revenue cycle at Jackson Healthcare.

However, it is the prompt access to all these documents that poses the greatest challenge to correct anesthesia coding.

“The biggest challenge for anesthesia practices is to take all the various documents and bring them into a single system for coding and billing,” Posey says. “Like most physicians that provide services within a hospital or health system, anesthesiologists are keenly aware of the data sharing and system integration issues.”

Chad Butts, owner of InterHealth Solutions, concurs. “Technology is available to monitor the concurrency of medical direction, track compliance with the seven steps, and identify documentation gaps,” he notes.

However, anesthesia groups face challenges, including the following, in advancing these IT capabilities:

• Anesthesia groups are still implementing new IT solutions and have limited budgets for larger EMRs. They typically have limited IT resources to integrate electronic documentation within their billing and coding platforms.

• Paper documentation prevails, and EMRs are usually owned by the hospital or health system. In cases where anesthesia documentation software exists, it is piggybacked on the hospital’s EHR and may be difficult to access or upload.

• Practices typically receive anesthesia records from hospitals in batch form, not concurrently or in real time.

With the push for EHRs and interoperability comes a push toward fully integrated revenue cycle management systems for anesthesia’s professional fee coding and billing. Platforms must integrate to ensure a workable solution for everyone—including coders.

Optimal technology solutions would also automatically identify and flag the following exceptions for coding and billing teams:

• Deficiencies: gaps or errors that prevent a patient account from being coded or billed;

• Discrepancies: items that can be coded or billed but lack consistency in physician documentation; and

• Validations: hard or soft stops in the coding process to validate additional items such as physician quality reporting system measures, missing data inputs, times, ICD-10 and procedure codes, place of service, and insurance-driven rules by the practice.

Given the ever-changing and complex nature of anesthesia coding, technology gaps will continue to be a challenge. However, it is imperative to maintain the highest integrity and accuracy when coding for anesthesia services.

It is up to coders to achieve data integrity, and, in turn, translate the documentation into accurate codes that communicate each patient’s encounter. This ensures practices consistently safeguard reimbursement and ultimately protect the patient’s best interest and trust.

— Weaver Hickerson is CEO of LightSpeed Technology Group.