Partners in Anesthesiology Billing In-service

1. Partners in Anesthesiology Billing In-service North Division Facilities

2. The anesthesia record is the legal document by which payers are billed. Any documentation intended to be considered for billing purposes appearing on the charge ticket alone will not be added to the claim

3. Cardinal Rules • NEVER ROUND TIME • ALWAYS USE A CONSISTENT TIME PIECE WHEN REPORTING TIME • Ensure all times are consistent with the OR staff times • Never pre-sign the anesthesia record for services rendered • Always confirm post op diagnosis and surgical procedure with surgeon • Do not used unapproved abbreviations • All Anesthesia Records must include a documented • pre induction vitals and immediate reassessment • before induction including the time Tony Mauk, FACHE

4. Cardinal Rules • Pre Anesthesia Evaluation: Must include at a minimum: • Review of the medical history, including anesthesia, drug and allergy history • Interview and examination of the patient (document heart and lung sounds) • Notation of anesthesia risk (e.g.. ASA classification) and Mallampati score, including OB • Identification of potential anesthesia problems, particularly those that may suggest potential complications or contraindications to the planned procedure (e.g.. Difficult airway, ongoing infection, etc) • Additional pre anesthesia evaluation, if applicable (stress test, etc.) • Development of the plan for the patient’s anesthesia care, including discussion with the patient or representative of the risks/benefits • Notation of personal communication with patient • Evidence that informed consent for anesthesia Tony Mauk, FACHE

5. Cardinal Rules • Post anesthesia evaluation follow up must document, at a minimum: • Respiratory function, including respiratory rate, airway patency and oxygen saturation • Cardiovascular function, including pulse and BP • Mental Status • Temperature • Pain • Nausea and Vomiting • Post operative Hydration • NOTE: Providers should document those patients who are unable to participate in the post op f/u. This documentation should include the reason for the patient’s inability to participate, as well as expectations for recovery time, if applicable. • For those patients who require long acting regional anesthesia to ensure optimum medical care of the patient, whose acute effects will last beyond the 48 hour time frame, a post anesthesia evaluation must still be completed and noted the patient is otherwise able to participate in the evaluation but full recovery from regional anesthesia has not occurred and is not expected within the stipulated timeframe of the completion of the evaluation Tony Mauk, FACHE

6. Definitions of Time • Anesthesia Pre Op Time – Time spent in the Prep and Holding Area performing “billable” tasks. Please see subsequent slides • Anesthesia Room Time: • Start - When patient rolls into the OR suite • Stop – When patient rolls out of the room to PACU, ICU, etc • (NOTE: Some of the older anesthesia records do not have Anes End/Care Transfer block as note below. This is the area you would record your Care Transfer/Anes End if you did not have that block) • Surgery Time: • Start – Knife to skin or surgeon start of procedure (ex. Injection of local, x-ray, etc.) • Stop – dressings on • Anesthesia PACU time: • Start – Patient rolls into PACU • Anes. End/Care Transfer – When anesthesia provider gives report and transfers care to the RN Tony Mauk, FACHE

7. Definitions of Time • If the anesthesia team meets an ICU patient in the prep and holding area, and then accompanies the patient to the OR, start time should reflect when care is initiated; • e.g. the transfer of care from the ICU nurse to the anesthesia provider. • If the EP lab staff brings a patient into the EP lab before the anesthesia care team is available, start time should reflect when the anesthesia care team started providing care. • Please document any unusual gaps in time that may occur while waiting for the surgeon or waiting for a PACU slot, etc. • All times do not end with a 0 or 5. Do not round time up or down. Tony Mauk, FACHE

8. Discontinuous time • The following are examples of billable services if performed outside the OR and properly documented: • IV starts for pre op sedation • Regional Blocks used as anesthesia for the case, where a separate surgical code is not billed for post op pain. This time can be continuous to OR time or discontinuous to OR time. • If billable anesthesia services are provided outside the OR, you must document three (3) items: • The event for which one is billing • The start time of the event, and • The end time of the event • BOTTOMLINE: KEY is documentation of PRE-OP start and stop time Tony Mauk, FACHE

9. Discontinuous time • Non billable services in the Pre and Holding Area due to bundled into anesthesia base units: • Pre op examination • Anesthesia Plan • Patient ID, chart review, consent, and answering questions • Patient reassessment • Transport time, unless medical necessity is documented Tony Mauk, FACHE

10. Induction and OR Time • In 2009, ASA adopted a new rule requiring the anesthesia provider to document the start and stop times of invasive lines and post op pain blocks inserted in the OR prior to induction of anesthesia. • These times must be deducted from the billable OR time because they are billed as a separate surgical code • If the line or block is placed in the OR after induction, the time does not have to be deducted Tony Mauk, FACHE

11. PACU Time • Any time over 15 minutes spent in recovery, while still billable, should have a detailed explanation on the record as to what prompted that amount of time to be spent in PACU. • Always use the actual times for your stop time/care transfer, do not round up or down time • If you anesthesia record has a box labeled “care transfer” fill in that box. If you record does not have a care transfer box, then write in the comments section words to that effect • Time spent on inserting lines (art line, CVP, Swan) in PACU is not billable time. These procedures are billed as flat fees without time being added. • Time spent inserting post op pain blocks in the PACU is not billable time. These procedures are billed as flat fees without time being added. Tony Mauk, FACHE

12. Billing for Lines and Blocks for Post Op Pain • Correct Example:A line by ________ 0700-0705; induction 0715. This allows the billing company to deduct 5 minutes because they know exactly how many minutes were spent and that it was prior to induction. • Documentation Rules: • If the line or post op pain block is placed in the Prep & Holding (P&H) there is no need to deduct time because it has not been counted as billable time. This is billed as a surgical code for the line or post op pain block • If the line or post op pain block is placed in the OR after induction, then no time is deducted as long as this is documented after induction. Provider will still need to document the start and stop times to show the procedure occurred post induction – may result in one unit reduction if start/stop times are not documented • You must document “for post op pain” so the billing department knows it was not part of the anesthetic. Tony Mauk, FACHE

13. Billing for Lines and Blocks for Post Op Pain • “Postoperative pain management services are generally provided by the surgeon who is reimbursed under a global payment policy related to the procedure and shall not be reported by the anesthesia practitioner unless separate, medically necessary services are required that cannot be rendered by the surgeon. The surgeon is responsible to document in the medical record the reason care is being referred to the anesthesia practitioner.” • CMS has strict requirements for post-operative pain management. The following is a summary of many regulations: • Postoperative pain management is global to the Surgeon’s package. • An exception to this is if medical necessity requires a remedy outside of the surgeon’s expertise. • A written request by the surgeon for you to perform a block/regional for postoperative analgesia is ideal, but in lieu of this, a note should be present in the surgeon’s documents as well as in your documents that this request wasmade by the surgeon for a post-operative pain block. • Post-op block cannot be the primary or part of the primary anesthesia. • Time spent placing the blocks for postoperative pain in the pre- or postoperative setting is not billable. Tony Mauk, FACHE

14. Billing for Lines and Blocks for Post Op Pain • In addition to above CMS rules, an ASA RVG 2009 article on Reporting Postoperative Pain Procedures in Conjunction with Anesthesia is summarized as: • If simply I.V. sedation were added to the block, then it would be clear that the block was a part of the primary anesthetic. • For a block to be billed separately, a general anesthetic would have to be used. • Time spent on placement, pre-or postoperatively placed, should be separately reported (this time is not billable). • Patient received additional information about the risks and procedures of such therapy and consented to this separately from the consent to anesthesia. Tony Mauk, FACHE

15. Billing for Medicare GI, MAC and Anesthesia for Pain • Medicare has categorized these procedures as Category B. On audit, Medicare will deny all anesthesia payments unless a qualifying diagnosis is documented regardless of the type of anesthesia (using Propofol does not mean you don’t need a qualifying diagnosis) • Documentation supporting, medical necessity should be legible • Indications that the procedure performed was deep, complex, complicated or markedly invasive • If no qualifying diagnosis exists consider an Advanced Beneficiary Notice (ABN) • In states where there is not a MAC LCD if the patient is not a P3 or above, you must either obtain an ABN, or submit the claim with a GZ mod and it will be denied appropriately Tony Mauk, FACHE

16. Billing for Medicare GI, MAC and Anesthesia for Pain-Continued • Michigan Anesthesia Care One, Tippecanoe Anesthesia Services • Medicare Contractor Wisconsin Physician Service www.wpsmedicare.com • This carrier does not have a MAC LCD • For patients that are not P3 or above an ABN must be obtained or payment will be denied • Milford Anesthesia Associates CT • Medicare Contractor National Government Services www.ngsmedicare.com • This carrier does not have a MAC LCD • For patients that are not P3 or above an ABN must be obtained or payment will be denied • Pinnacle Mid Atlantic, Redstart Medical Practices • Medicare carrier Novitas Solutions www.novitas-solutions.com • This carrier does have a MAC LCD Tony Mauk, FACHE

17. Medical Direction Guidelines • Anesthesiologist medically directing up to four (4) concurrent procedures • If the Anesthesiologist takes on more than four (4) concurrent procedures or performs other services while directing the concurrent procedures, he/she is supervising; therefore, the MDA is paid only 3 base units (plus one additional unit if present at induction), but no time units for all such Medicare cases. • The Anesthesiologist is allowed to do the following while Medically Directing: • Addressing an emergency of short duration in the immediate area • Administering an epidural or caudal anesthetic to ease labor pain • Periodic, rather than continuous, monitoring of an OB patient • Receiving patients entering the operating suite for the next surgery • Checking on or discharging patients from PACU • Coordinating scheduling matters Tony Mauk, FACHE

18. Medical Direction • Medical Direction is a covered service only if the physician: • Performs a pre anesthetic exam and evaluation • Prescribes the anesthesia plan • Personally participates in the most demanding procedures of the anesthetic plan, including induction and emergence • Ensures that any procedure in the anesthesia plan is performed by a qualified individual • Monitors the course of anesthesia at frequent intervals • Remains physically present and available for immediate diagnosis and treatment of emergencies • Provides indicated post anesthesia care (If the physician leaves the immediate area for more than a short duration or devotes extensive time to an emergency case, the physician services to the surgical patient is supervisory in nature and not reimbursed by Medicare under medical direction rules

19. Coding for Anesthesia Cancellations • Prior to the induction of anesthesia, bill appropriate E&M • After the induction of anesthesia, bill intended procedure and any documented time  Concurrency & Modifiers • Physician Personally Performing:  AA • Medically Directing: • QK - 2, 3, or 4 concurrent procedures • QY - medically directing one anesthetist • Medical Supervision: • AD – more than 4 concurrent procedures • Locum Tenen Physicians: Q6 • CRNA: • QX - medically directed by a physician • QZ - acting alone (LCD) Tony Mauk, FACHE

20. Coding for Anesthesia Physical Status Modifiers • P3 - Patient with severe systemic disease. • P4 - Patient with SDS that is a constant threat to life. • P5 - A moribund patient who is not expected to survive w/o the operation. • P6 - A declared brain-dead patient whose organs are being harvested for donor purposes. • Additional Flat Fees • Controlled Hypothermia - 99116 • Controlled Hypotension - 99135 • Age - 99100 • Emergency - 99140 • These conditions are considered global by Medicare; although they are payable by many commercial carriers. Tony Mauk, FACHE

21. Teaching Physician Student Nurse Anesthetists: MD can only direct 2 SRNAs in concurrent cases. Residents: Medicare pays an unreduced fee schedule payment if a teaching anesthesiologist is involved in a singe procedure with one resident, two concurrent anesthesia cases involving residents, or a single anesthesia case involving a resident that is concurrent to another case paid under the medical direction rules. The teaching physician must document in the medical record he/she was present during all critical or key portions of the procedure. Tony Mauk, FACHE

22. Billing for Obstetric Anesthesia • Anesthesia Record must reflect the start and stop time of Labor or the C-Section • Documentation Rules: • Insertion time of epidural for labor (start/stop). Time starts when beginning to prepare the patient for the procedure and ends when procedure completed. • Document each bolus injection • Frequent monitoring checked off on anesthesia grid for continuous epidural • Delivery – record time of birth on record (stop time of continuous labor epidural • Document time of removal of epidural catheter Tony Mauk, FACHE

23. ASA Guidelines re: OB Anesthesia • Methods to determine professional charges: • Base units plus time units (insertion through delivery) subject to a reasonable cap • Base units plus one unit per hour for neuraxial anesthesia management plus direct patient contact time (insertion, management of adverse effects, delivery, removal) • Incremental time – based fees (e.g. 0<2 hours, 2-6 hours, > 6 hours • Single fee Tony Mauk, FACHE

24. Billing Rules for TEE • Medicare pays for two TEE codes • Probe placement only (93313) • Probe placement and the formal TEE interpretation (93312-26) • Provider must document the diagnostic purpose of the TEE, e.g. “TEE to • diagnose ________ and list the diagnosis justifying the purpose of the TEE on • the record • Medicare also pays for Doppler pulsed or continuous wave (93320) and color flow velocity mapping (93325). However, the verbiage of the Doppler and color flow should appear in the documentation to warrant billing these two codes. This must appear on the anesthesia record…not only on charge ticket and cannot be assumed Tony Mauk, FACHE

25. Ultrasound Guidance • Three things are required for ultrasound for vascular access such as a central line (76937): • A permanently recorded image showing the needle in close proximity to the nerve (post op pain blocks; 76942) • A statement that ultrasound was used to visualize the vasculature available for access • Ultrasound was used to visualize the needle or catheter going into the named vessel • In all three cases, a permanent recorded image must be included in the patient record, as well as, a documented description of the above process either separately or within the procedure report. • For the instances when ultrasound is used only to identify the vein, mark a skin entry point and proceed with non guided puncture it is not appropriate to report code 76937 for ultrasound guidance Tony Mauk, FACHE

26. Amending the Medical Record • There are 3 types of legitimate changes which can be made to the medical record: • late entries – supplying additional information that was omitted in original entry • addenda • corrections. • All changes must bear the current date of change and must be signed or initialed by person making the change. The change cannot be backdated. Tony Mauk, FACHE

27. Delayed Dollars • If there are missing items on the charge sheet and/or the anesthesia record the charge must wait for the research to be performed and at times entire batches are held. • Example: • TEE – Medicare and certain other payers required “qualifying diagnosis”. The TEE must have a different diagnosis than that of the CABG • Primary Diagnosis: Copied from the patient demographic sheet rather than noting the post op diagnosis • “Rule Out”/ “Possible”/ “Normal” as a diagnosis. Must have post op diagnosis or a sign or symptom related to the condition • “Poor Prep” as a diagnosis for a cancelled colonoscopy. Code diagnosis as appropriate, for example, screening or other appropriate diagnosis. Although the procedure is cancelled we will be paid for time spent with patient, if documented correctly. • Procedure and Diagnosis that do not match • Lack of signature: Must be legible. Medicare has the option to deny payment if the signature is illegible on the anesthesia record • Post Op Pain Visit: Indicate the surgical diagnosis, example: colon cancer • Intubations and IV starts performed outside the OR require diagnosis, example: respiratory distress or dehydration Tony Mauk, FACHE

28. Documentation Tips • Upper vs. Lower: • Exploratory Laporatomy • Lower – 6 units • Upper - 7 units / Document “Upper Ex Lap” if accurate • Upper 2/3 of Femur • Open procedure – 6 units • Lower 2/3 of Femur • Open procedure – 5 units / Document “Upper 2/3 Femur” if accurate • Knee Scope • Diagnostic Arthroscopic – 3 units • Surgical Arthroscopic – 4 units / Document “Surgical or –ectomy or –plasty” Tony Mauk, FACHE

29. Documentation Tips • ICD Implant • ICD implant alone – 7 units • ICD implant with EP testing – 10 units Document: “EP Testing” on the procedure line of the anesthesia record, if appropriate • Pacemaker • Insertion or Replacement of Generator – 3 units • Insert Pacemaker and Leads – 4 units • Removal of Generator – 3 units Document: “Leads” • SCS Implant • Trial Leads Implanted – 5 units • Implant Generator – 5 units (Back); 3 units (Front) Document: “Front” or “Back Tony Mauk, FACHE

30. Documentation Tips Mediport:Insertion: 4 units Removal: 3 units Document: “Implantation” or “Removal” Baclofen Pump: Insertion: 5 units (Back) 3 units (Abdomen) Trial Tunneled Catheter – 5 units ACDF: One Level, No Hardware – 10 units More than one level - 13 units Document: “Levels” or “Hardware” Tony Mauk, FACHE

31. Documentation Tips • Lumbar Discectomy and Fusion: • Single Level, no hardware – 8 units • Two or more levels or instrumentation – 13 units • Ileostomy Revision: • Simple (scar release) – 4 units • Complicated (reconstruction) – 7 units • One Lung Ventilation: • Thoracotomy – 12 units (without one lung vent) 15 units (with one lung vent) • Document: “one lung vent,” if appropriate, on the procedure line of the anesthesia record Tony Mauk, FACHE

32. Documentation Tips • TEE • 93313 • Prove placement only • Document diagnostic purpose • Some states have a LCD (local coverage determination) • 99312 • Placement and ECHO report • Diagnostic purpose • 93318 • For Monitoring, not paid by Medicare Tony Mauk, FACHE

33. Documentation Tips • Orchipexy: • Inguinal approach – 4 units • Via laparoscopy – 6 units • Abdominal approach – 6 units Document “the approach” • TAH: • TAH: 6 units • TAH w/lymphadenectomy – 8 units • Document: Do not say “TAH with staging” (may or may not be radical) • Hip: • Bipolar Hip – 6 units (not a total hip) • Total Hip – 8 units Document: “total hip” on the procedure line of the anesthesia record, if appropriate Tony Mauk, FACHE

34. Documentation Tips AAA: Open – 15 units Endovascular – 10 units Document: the approach Intracranial Procedures: NOS - 11 units Sitting Position – 13 units Document: Sitting position, if applicable Lung Biopsy: Via Bronchoscopy – 6 units Via Percutaneous Needle – 4 units Document: the approach Breast Biopsy with Axillary Node Dissection: Simple Breast Biopsy – 3 units Axilla – 5 units Tony Mauk, FACHE