1 Anesthesia Coding and Compliance Presented by: Melanie Lafferty June 2015
2 Conflict of Interest Disclosure Statement Melanie Lafferty, Vice President of Practice Management Medac, Inc. I have the following financial relationships to disclose: I am a Vice President of Practice Management for Medac, Inc., an Anesthesia Billing and Practice Management company. I will not discuss off-label use during my presentation..
3 Introduction The target for this training is to provide you with a basic understanding of anesthesia coding and compliance in regards to the following topics: Documentation Time Coding Medical Direction Additional billable services Mode of Anesthesia Medical Necessity
5 Why is Documentation Important? Office of Inspector General (OIG) CMS Recovery Audit Contractor Program (RAC) Office of Civil Rights - HIPAA Audits performed by Payors Medicare and Medicaid Reporting Center - Whistleblowers are financially rewarded
6 Documentation If it is not documented, it did NOT happen. Documentation is key and leads to: Accurate Coding Appropriate use of modifiers Billing compliance Maximized reimbursement
7 Documentation, cont. Each provider on case must sign the record (including relief providers) If electronically signed, must state: Electronically signed by For the Centers for Medicare and Medicaid Services (CMS) the signature must be legible It is recommended that if your signature is illegible you print your name next to your signature
8 Documentation, cont. The anesthesia record must provide the details needed to generate a claim. Who (Patient, MD, CRNA) What (Procedure Description, lines placed, P- status, etc.) When (Date, start/stop times, relief times, etc.) Where (facility name/or #) Why (diagnosis)
10 Definition of Anesthesia Time Anesthesia time is defined as the period during which an anesthesia practitioner is present with the patient. It starts when the anesthesia practitioner begins to prepare the patient for anesthesia services in the operating room or an equivalent area and ends when the anesthesia practitioner is no longer furnishing anesthesia services to the patient, that is, when the patient may be placed safely under postoperative care. Guidance/Guidance/Manuals/downloads/clm104c12.pdf
11 Anesthesia Start Time Time is counted from the moment the practitioner -- having completed the preoperative evaluation starts an intravenous line, places monitors, administers pre-anesthesia sedation or otherwise physically begins to prepare the patient for anesthesia.
12 Billable Pre-OR Start Time Administering sedation Regional block used as mode of anesthesia For these: Need a start and end time Example IV start/pre-op meds; in OR 0706 Incorrect Example IV start/pre-op meds; 0700 in OR 0706
13 Discontinuous Time for Lines & Blocks 2015 Relative Value Guide (pg. 60) Time for a post surgical block that occurs after induction and prior to emergence does not need to be deducted from reported anesthesia time. Discontinuous Time 07:06-07:14 07:03 AM 07:06 AM 07:14 AM 08:09 AM
14 When Does Anesthesia Time End? The Anesthesia Answer book defines anesthesia end time as when the anesthesia practitioner is no longer in personal attendance, i.e. when the patient may be safely placed under post-operative supervision. Commonly referred to as the Transfer of Care time.
15 Stop Time Document the time you transfer the care to the PACU staff Document the following: Vitals until you exit the OR Final patient status when transferring care
16 Stop Time Discussion Extended time after emergence from the primary anesthetic should be supported on the anesthesia record by: Documentation of events that prolonged your attendance.
17 Anesthesia Time Enter exact times only- DO NOT round times up or down or use intervals of 5. The end time and start time between abutting cases must be documented at least one (1) minute apart.
18 Anesthesia Time, cont. Relief When one practitioner relieves another during a case, the record must clearly reflect the relief times (start and stop) and the provider rendering the relief Use military time only Utilize one consistent time piece Personal watch Atomic clocks that are synced
19 Anesthesia Time, cont. Time spent performing the pre-anesthesia assessment or post-anesthetic evaluation (after release to PACU) is NOT billable time and should not be calculated in with your reportable anesthesia time
20 Second Anesthesia Provider Per the ASA, When it is necessary to have a second attending anesthesia provider assist with the provision of anesthesia, these extraordinary circumstances should be substantiated by special report. Supporting Documentation Medical Necessity for 2nd anesthesia provider Detailed documentation of the anesthesia services provided what roles did each provider take in provision of care to the patient Medical record document must support the start and stop time of the 2nd provider
21 Canceled Anesthesia Case Canceled prior to induction surgery not rescheduled within 48 hours Bill appropriate E/M code per documentation in the preanesthetic evaluation (subsequent hospital visit) (new patient office/outpatient) (subsequent patient office/outpatient) Canceled after induction Bill applicable ASA code with base and time Add modifier 53 for discontinued procedure
23 Coding Descriptions Procedure/Diagnosis coding provides an accurate representation of the health care services through complete and precise documentation Detailed documentation should include definition of severity, comorbidities, complications, manifestations, causes and any other characteristics that classify the patient s condition.
24 Coding for Accurate Reimbursement Surgical vs. Diagnostic Positioning- prone, RLD, LLD
25 Coding for Reimbursement, cont. Integumentary Systems- anatomical site Axillary region (node biopsy/lumpectomies)
26 Coding for Reimbursement, cont. One lung ventilations (OLV) Cardiac Bypass- on/off pump
27 Coding for Reimbursement, cont. Abdomen- upper/lower Hernias- specify with or without obstruction/strangulation Stones- specify kidney, upper ureter, ureter or bladder
28 Coding for Reimbursement, cont. Limbs- distal/proximal Replacement vs. revision joint replacement
29 Coding for Reimbursement, cont. Instrumentation/multiple levels on spinal surgeries
30 ASA Relative Value Guide (RVG) Coding Comment Anesthesia for extensive spine and spinal cord procedures (eg, spinal instrumentation or vascular procedures) RVG COMMENT: Code is appropriate only if the surgical procedure includes segmental or nonsegmental instrumentation as defined in CPT or if the procedure includes multiple vertebral segments (minimum three vertebral bodies with the two associated interspaces.)
31 Medical Direction Criteria (7 steps) 1. Performs a pre-anesthetic examination and evaluation; 2. Prescribes the anesthesia plan; 3. Personally participates in the most demanding procedures of the anesthesia plan, including induction and emergence; (when applicable) 4. Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist; 5. Monitors the course of anesthesia administration at frequent intervals; 6. Remains physically present and available for immediate diagnosis and treatment of emergencies; 7. Provides indicated-post-anesthesia care. Code of Federal Regulations (C.F.R.) (a); Medicare Part B Carriers Manual C
32 CRNA Modifiers QY- Medical Direction Medical direction of one CRNA by a physician QX - CRNA medically directed with medical direction of 2-4 CRNAs by a physician QZ- CRNA Service without medical direction by a physician
33 MD Modifiers Medical Direction (QK modifier) When the anesthesiologist is managing no more than four qualified providers (CRNA s) The medical record substantiates that the anesthesiologist is in compliance with CMS seven steps. Medical Supervision (AD modifier)ad modifier) When the anesthesiologist is managing more than four cases OR The medical record does not substantiate that the anesthesiologist is in compliance with CMS seven steps.
34 Physical Status Modifiers P1- Normal, healthy patient P2- Patient with mild systemic disease P3- Patient with severe systemic disease (includes morbid obesity) - ONE BASE UNIT P4- Patient with severe systemic disease that is a constant threat to life. - TWO BASE UNITS P5- Moribund patient who is not expected to survive without surgery. - THREE BASE UNITS P6- Declared brain-dead patient whose organs are removed for donor purposes
35 Qualifying Circumstances Modifiers Extreme age (Under 1 or 70 yrs or >) 1 Base Unit Hypothermia (20'C or below) 5 Base Units Should include documentation of surgeon's request" Hypotension 5 Base Units Controlled or induced hypotension is billable only when done in a deliberate and formal manner and per surgeon s request Emergency 2 Base Units [A]n emergency is defined as existing when delay in treatment of the patient would lead to significant increase in the threat to life or body part.
36 Invasive Monitoring Lines A-line, CVP, and Swan-Ganz catheter Documentation in anesthesia record should support performance of the procedure (who, needle/cath size, and location) Ex: 20g rt radial a-line placed atraumatically Bill under provider who performed the service OK to bill both CVP and Swan Ganz if two separately documented lines (two insertion sites)
37 Ultrasound Guidance Ultrasonic guidance for needle placement (e.g. biopsy, aspiration, injection, localization device), imaging supervision and interpretation. Requirements: Permanent recorded images of the site to be localized Documented description of the localization process Ultrasound guidance for vascular access, has specific requirements that must be met. Requirements: Ultrasound evaluation of potential access sites Documentation of selected vessel patency Concurrent real-time ultrasound visualization of vascular needle entry Permanent recording and reporting
38 Post-op Pain Management Includes epidurals, spinals and peripheral nerve blocks May be billed as a separate service if placed for post op pain management and is NOT the primary anesthetic technique The anesthesia for the surgical procedure was not dependent upon the efficacy of the regional block Time spent on pre- or postoperative placement of the block is separated and not included in reported anesthetic time Placement billed on same day as surgery w/ -59 modifier Requires documented transfer/request of care for post-op pain management from surgeon
39 Post-op Pain Management A procedure note should be included in the medical record to identify the location, technique, drugs, complications, and the performing provider, along with documentation to support the procedure was for post-op pain management at surgeon s request.
40 Post-op Pain Management Medicare administrative contractors (MAC) have recently made changes to their post op pain management LCD s. Noridian: Reimbursement for the control or management of acute pain in the immediate postoperative period is generally packaged into the payment for the surgical procedure. However, if a need for transfer of pain management is documented and ordered by the surgeon and the accepting provider documents the need for and acceptance of transfer of care, separate reimbursement may be made for the service. WPS: 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.
41 Post-op Pain Management daily hospital management of epidural/subarachnoid continuous drug administration Billed beginning the day after catheter placement Not appropriate for follow-up of peripheral nerve catheters, Duramorph rounding (no existing catheter) or IV PCA management Use if follow-up care is required (medically necessary) for a single injection, continuous infusion by catheter nerve block or duramorph rounding Typically, a low level subsequent hospital visit (99231) is most often supported Not billable if provided the same day as block/catheter insertion Duramorph rounding (no existing catheter) is only billable if placed for post-op pain and the mode of anesthesia for surgery was general anesthesia
42 Post-Operative Pain Rounding E&M CPT Code Documentation should include that the majority of the visit was to assess if there were any side effects from the injection and the drug that was administered. There must also be documentation to support the clinical medical necessity of rounding on the patient because of the nature of the drug and the duration that the drug stays in the body.
43 Post-Operative Pain Rounding E&M CPT Code The CPT manual also dictates specific requirements for billing the E&M service. The CPT manual specifies the following requirements: Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components. A problem focused interval history; A problem focused examination; Medical decision making that is straightforward or of low complexity.
44 Mode of Anesthesia General Monitored Anesthesia Care (MAC)
45 General Anesthesia General Anesthesia: a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory support is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired. Per the 2015 Relative Value Guide book (page 47) If the patient loses consciousness and the ability to respond purposefully, the anesthesia care is a general anesthetic, irrespective of whether airway instrumentation is required.
46 Monitored Anesthesia Care (MAC) Monitored Anesthesia Care (MAC): anesthesia care that includes the monitoring of the patient by a practitioner who is qualified to administer anesthesia as defined by the regulations at (a). Indications for MAC depend on the nature of the procedure, the patient s clinical condition, and/or the potential need to convert to a general or regional anesthetic. Per the 2015 ASA Relative Value Guide Position on MAC (page 47) Monitored anesthesia care includes all aspects of anesthesia care. Monitored anesthesia care may include varying levels of sedation, analgesia, and anxiolysis as necessary. The provider of MAC must be prepared and qualified to convert to general anesthesia when necessary. Medicare Administrative Contractors have very specific MAC policies. It is imperative that you understand the requirements for reimbursement of MAC procedures from your local Medicare Contractor.
47 Monitored Anesthesia Care Modifiers QS - Monitored anesthesia care service G8 - Monitored anesthesia care (MAC) deep complex complicated, or markedly invasive surgical procedures G9 - Monitored anesthesia care (MAC) patient w/ history of severe cardio- pulmonary condition
48 Medical Necessity Defined as those services that are reasonable and necessary for the diagnosis or treatment of an illness or injury, or to improve the functioning of a malformed body member and are not excluded under a patient s insurance plan. The necessity of the procedure must be carefully documented and must meet the standards of good medical practice in the local area.
49 Medical Necessity You must demonstrate that the services are not mainly for the convenience of the patient or provider. Pay particular attention to carefully document medical necessity for: MAC GI procedures Skin procedures Cath Lab procedures Spinal and minor joint injections Post-op pain Invasive Lines
50 Questions? Melanie Lafferty VP of Practice Management
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