Upholding accuracy and trust in healthcare data is more important as ever. And it is critical to know how to properly and effectively navigate anesthesia coding rules, regulations and payer policies. That has long been a challenge, given the ever-changing and complex nature of anesthesia coding. Still, with a clear understanding of overarching coding challenges and three specific focus areas, practices can consistently achieve integrity in anesthesia coding and safeguard payer reimbursement.
Understanding Common Anesthesia Coding Challenges
Anesthesia is one of the most difficult areas to code due to its complex documentation. Accuracy is paramount, and the physician must document all procedures performed while the patient was under anesthesia. Specific protocols exist for every stage of anesthesia treatment.
Common challenges in anesthesia documentation include:
- Lack of access to anesthesia records, operative reports, and other hospital-based patient information
- Allocation of anesthesia time
- Medical direction versus medical supervision
- Compliance with the seven steps of medical direction
- Careful monitoring of overlapping cases by a single anesthesiologist
- 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. Failure to recognize these challenges and practice accordingly can lead to revenue loss and even fraudulent claims.
- Recognize 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 (CRNA) or a physician assistant (PA) trained in anesthesia. Successful coding of medical direction relies on compliance with seven elements agreed upon by both the American Society of Anesthesiologists and Medicare. Though most coders and anesthesia professionals are keenly aware of the seven steps of medical direction, it is imperative that they review frequently to ensure proper and consistent documentation.
To support medical direction, physicians must document that they performed each of seven medical direction functions:
- Perform a pre-anesthesia exam and evaluation
- Form an anesthesia plan
- Be present for all critical portions of the procedure, including induction, emergence, and any other demanding portion of the procedure
- Ensure that a qualified individual performs any procedure in the anesthetic plan not personally performed by the supervising physician
- Frequently monitor the course of anesthesia administration
- Remain immediately available for any potential emergency situations
- Provide post-anesthesia care and orders
If any of the seven steps for medical direction is not performed or a procedure that is not allowed under medical direction is performed, then it will be designated as medical supervision which will result in a lower reimbursement.
- Use Modifiers for Correct Anesthesia Coding
Knowing what constitutes medical direction is only part of the challenge. Coders must also understand the proper use of anesthesia modifiers. A modifier is a two-digit alpha or numerical code added to clarify billed services. These modifiers are essential for clarifying whether an anesthesia procedure was personally performed, medically directed, or medically supervised by an anesthesiologist. They are also payment driven by payer and vary based on type of provider.
For every anesthesia procedure billed, coders are required to use basic modifiers to identify specific situations, which increases coding consistency, eliminates the appearance of duplication, and improves reimbursement accuracy.
For more examples of proper and improper use of anesthesia modifiers refer to the American Medical Association (AMA) toolon coding resources.
- Ensure Clear and Accessible Anesthesia Documentation
Clear documentation is the most important piece for coders to ensure accuracy. Given the various documents involved in anesthesia coding, the biggest challenge for anesthesia practices is to bring all the documents into a single system for coding and billing.
Viewing all documents ensures better coding and improves reimbursement. Above all, it is necessary to make sure all documents are accessed promptly.
Technology is available to monitor the concurrency of medical direction, track compliance with the seven steps, and identify documentation gaps. However, anesthesia groups face the following challenges in advancing these IT capabilities:
- Limited budgets and resources prevent full integration of electronic documentation in their billing systems.
- Paper documentation and manual coding are still heavily used by several EMRs and practices, which can be difficult to upload or access.
- Practices typically receive anesthesia records from hospitals in batch form, not concurrently or in real time.
Anesthesia Coding and Revenue Cycle Management Systems
To promote accurate and seamless coding, there has been a push toward fully integrated revenue cycle management systems for anesthesia’s professional fee coding and billing. Platforms must integrate to ensure a workable all-inclusive solution. Ideal 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
- Validations—hard or soft stops in the coding process to validate additional items such as PQRS measures, missing data inputs, times, ICD10 codes, procedure codes, place of service, and insurance-driven rules by the practice
Essentially, accurate anesthesia codingand billing require in-depth knowledge about all challenges and evolving rules, regulations and policies. Coders must maintain the highest standards of compliance to achieve data integrity. This will ensure that practices consistently safeguard reimbursement and protect the patient’s best interest and trust.