The ABCs of Calculating Anesthesia Time Units

calculating anesthesia time units

It’s essential to stay vigilant when it comes to calculating anesthesia time units. Not properly doing so can result in delayed or denied claims, decreased revenue, and audits – which can have a negative impact on your practice’s reputation.

Take a moment to look over this guide on the basics of calculating anesthesia time units so that your claims go through smoothly and accurately.

How to Determine and Report Anesthesia Time

Anesthesia time begins the moment the provider (the anesthetist) begins preparation for the patient, whether it’s in the operating room or in another area. An important thing to note is that any time spent looking over the patient’s medical records before surgery is not considered “anesthesia time” and is not billable. Instead, this is considered preoperative evaluation, and will be calculated in the base units.

The end of anesthesia time is marked by the moment the anesthetist is no longer personally attending the patient, and the patient has been moved into post-anesthetic care.

When it comes to the logistics of how one should report anesthesia time, the appropriate unit is 15-minute increments. Each 15-minute segment of anesthesia time is reported as one unit of time. So a 45-minute procedure would be considered three units of anesthesia time.

Accuracy is essential here, since Medicare pays to a tenth of a unit. Estimations of time are not appropriate. If the procedure lasts for 63 minutes, for example, then 4.2 time units would be reported – and that time should not be rounded up or down.

How to Calculate Reimbursement

There are specific formulas used to calculate reimbursement for a procedure based on the time units calculated for anesthesia time. The formula you use depends on who administered the anesthesia.

The formula for anesthesiologists or CRNAs would be:

(Base Factor + Total Time Units) x Anesthesia Conversion Factor x Modifier Adjustment = Allowance

The formula for anesthesia performed under medical direction would be:

[(Base Factor + Total Time Units) x Anesthesia Conversion Factor] x Modifier Adjustment = Allowance for each provider

Again, accuracy is essential, as your process for calculating anesthesia time units can directly impact the overall charge, which then impacts your practice’s revenue.

What Else Should You Know About Calculating Anesthesia Time Units?

There are other considerations to be made here, too. For example, if there are interruptions in anesthesia care during a procedure, the exact times of the interruption should be recorded so that discontinuous time can be accounted for and any time that the anesthetist was not personally attending the patient will not be counted.

Additionally, most insurers will not allow for any more than one time unit for preparing patients for postoperative transfer to recovery. They also don’t allow you to bill for time that the patient is in a waiting room or another type of holding area. Patients also can’t be billed for any blood products or antibiotics that are given to them in a holding area, especially when those things could have been administered in a different part of the facility.

Questions about billing and coding? Get more information about how we can take that burden off your shoulders.

The ABCs of Physical Status Modifiers

physical status modifiers

Accuracy is essential when it comes to physical status modifiers in the anesthesiology field, and as of January 2016, the ASA Physical Status Classification System (modifiers P1-P6) includes examples to assist in choosing the appropriate modifier.

The original version was published in 1941 by Meyer Saklad, and then by ASA in a booklet for the members of its organization. In Saklad’s opinion, the pre-operative classification of a patient’s physical status was a very useful statistical tool, and he was adamant that “no attempt should be made to prognosticate the effect of a surgical procedure upon a patient of a given Physical State.”

In 1962, when the ASA published a revised version of Saklad’s system, it failed to include examples. Numerous studies have proven that clinicians’ assignments of PS modifiers are quite subjective and not prone to consistency, resulting in multiple PS classes assigned to the same patient.

A Wide Range of Uses

Now, the ASA PS Classification System is used for many purposes beyond the characterization of a patient’s physical status as it relates to anesthesiology. Things like paying for anesthesia services, allocating risk, and predicting perioperative risk are all included in those purposes. For this reason, the ASA chose to use the following examples in its system so that classifications become more uniform.

physical status modifiers

The more consistency we can have in physical status modifiers, the better, because everything from work assignments to finances are affected by them.

Need help with your practice’s medical coding? Find out how we can help.

The ABCs of MAC Anesthesia

mac anesthesia

You may have heard about MAC anesthesia, or maybe you know someone who experienced this type of sedation during surgery – but what exactly is it, and how does it differ from general anesthesia? These are great questions, and they concern a lot of people – especially those who claim they’ve been awake during surgery.

Read on to learn the basics of MAC anesthesia.

What Is MAC Anesthesia?

MAC stands for Monitored Anesthesia Care. Rather than just knocking you out, anesthetic medications are used to put you through a range of sedation levels. The level you reach depends on a variety of things — like your age, health, genetic factors, and how much of the drug you are given.

According to The American Society of Anesthesiologists (ASA), levels of sedation are divided into the following four categories. Each category’s official ASA definition is given next to it.

  •      Minimal Sedationa drug-induced state during which patients respond normally to verbal commands.
  •      Moderate Sedationa drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation.
  •      Deep Sedationa drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation.
  •      General Anesthesiaa drug-induced loss of consciousness during which patients are not arousable even by painful stimulation.

MAC does not appear in these official classifications, but it is most closely associated with moderate and deep sedation.

Why Are There Levels of Sedation?

Since most people prefer to be completely unaware during surgery, it begs the question: what’s the point of minimal and moderate sedation? There are two main reasons lighter sedation is sometimes used: recovery is much quicker, and there is less depression of the patient’s breathing and heart rate (as opposed to heavier drugs, which cause the patient to gradually lose the ability to breathe normally).

The most important thing about MAC anesthesia is to have a clear understanding of the level of sedation you are being offered before surgery. You should know exactly what to expect as far as your awareness and memory of the procedure (some anesthesia has the happy side effect of causing amnesia as far as the surgery goes).

Other problems can arise if the patient does not respond as expected to the sedation, and ends up either too lightly or too heavily sedated – but even with general anesthesia, there are about 2 in every 1,000 cases where patients are unintentionally aware.

MBM Supports Anesthesiology Practices

Our job is to handle your anesthesiology practice’s billing and coding so that you can focus on your patients, your staff, and your clinic. Contact us today for more information on how we can help!

The ABCs of CPT Modifiers

cpt modifiers

Because of the complexity of medical procedures and services, additional information is often necessary when coding. This information typically comes in the form of what’s called a CPT modifier, which describes how many procedures were performed, why they were necessary, where they were performed on the body, how many surgeons were involved in the operation, and more.

Below, we’ll go over the basics of CPT modifiers and how to use them correctly.

How Are CPT Modifiers Constructed?

CPT modifiers are always made up of two characters, either numeric or alphanumeric. Most are numeric, but some anesthesia modifiers are alphanumeric.

These modifiers are attached to the end of a CPT code without a hyphen. If you have more than one modifier, you’ll code the “functional” one first, followed by the “informational” one. How can you tell the difference? It’s easy – list the modifier that affects the reimbursement process the most directly first.

Why Does Order Matter?

The reason we list modifiers in a certain order is that payers don’t always consider modifiers after the first two. (CMS-1500 and UB-04 provide space for four modifiers, though.) Because of this, the first two modifiers are the most important ones, and you want to make sure they are visible.

What’s an Example of a CPT Modifier in Anesthesia?

Anesthesia has its own special set of modifiers that correspond to the patient’s condition as anesthesia is administered. The following is a list of these codes:

  •      P1 – a normal, healthy patient
  •      P2 – a patient with mild systemic disease
  •      P3 – a patient with severe systemic disease
  •      P4 – a patient with severe systemic life-threatening disease
  •      P5 – a moribund patient who is not expected to survive without the operation
  •      P6 – a declared brain-dead patient whose organs are being removed for donor purposes

These codes are pretty straightforward, but let’s consider an example of how they might be used. If a patient needs to be anesthetized before undergoing a procedure, then you would turn to the appropriate section of the CPT codebook and find the correct code that you need. If your patient is otherwise in good health, you would add the P1 modifier to your code.

Need Help with Your Coding and Billing? Contact MBM Today!

If you’re ready to let Medical Business Management worry about your practice’s coding and billing so that you can focus on your patients, contact us to start a conversation about our services. We are ready to remove that burden from your shoulders – and there’s no one better able to handle it than us!

Regional Anesthesia Has Positive Impact on Bundled Payments

regional anesthesia

Regional anesthesia has been shown to have a positive impact on pain scores, length of stay, postoperative nausea and vomiting, time in post-anesthesia care, and opioid use / adverse events. And according to Sonia Szlyk, MD, speaker at the Interdisciplinary Conference on Orthopedic Value-Based Care, it has also shown to have a positive impact on bundled payment programs.

Avoiding Opioids

“One of the reasons why regional is so impactful is because it allows us to be opioid sparing,” Szlyk said. “Opioid-related adverse events are costly and common. If you can do anything to reduce the patient’s need for opioids or reduce the risk of opioid-related adverse events, you are going to be more successful in a positive bundle payment scenario.

According to a study published in Pain & Palliative Care Pharmacology, 12.2% of 320,000 patients who underwent a total hip or total knee replacement experienced an opioid-related adverse event. As noted by Szlyk, this added a substantial cost to the system and would destroy the bundle. This was because patients stayed in the hospital 3.3 days longer; hospital costs increased $4,707 on average, and the 30-day readmission rate rose.

More Benefits of Regional Anesthesia

In addition to its positive effect on bundled payments, regional anesthesia boasts a whole list of benefits, including:

  •      Decreased pain scores
  •      Decreased emergency room and hospital readmission
  •      Reduced need for acute rehabilitation and skill nursing facilities
  •      Less post-anesthesia care unit time
  •      Increased patient and surgeon satisfaction

According to a meta-analysis in Regional Anesthesia and Pain Medicine, the incidence of surgical site infections was decreased with neuraxial anesthesia as opposed to general anesthesia. And another study published in Anesthesiology that included over 380,000 patients who had undergone total hip or knee replacements at 400 different hospitals showed a decreased rate of 30-day mortality and in-hospital complications with neuraxial anesthesia compared with general anesthesia.

MBM Cares About Anesthesiologists and CRNAs

When it comes to navigating the world of value-based care and bundled payments, nobody knows the industry better than Medical Business Management. Contact us today for more information on how we can take the billing and coding burden off your shoulders so you can focus on your practice.

3 Things Physicians Will Bring Before State Legislators This Year

physician advocacy

As physicians enter 2017, there are a number of concerns that will occupy their advocacy efforts for the year. In a survey of more than 65 state and specialty societies, the top issues for 2017 include the nation’s opioid epidemic, Medicaid expansion, private payer reforms, and numerous public health issues.

Below are three issues physicians will advocate for in 2017.

#1: Medicaid

Many states are buckling up for debates surrounding Medicaid’s expansion, as well as for Medicaid reforms to improve patient access and quality of care.

Alabama, Delaware, Massachusetts, Maryland, Nebraska, Nevada, Rhode Island, and Vermont plan to deal with accountable care organizations, while Connecticut, Massachusetts, Maryland, Nevada, and Kentucky will address delivery system reform incentive payments (DSRIP) programs.

As for funding, Alabama, California, Illinois, Michigan, Mississippi, Ohio, Oklahoma, Oregon, and Wyoming are just a handful of the many states dealing with issues concerning Medicaid.

#2: Opioid Epidemic

Across the country, physicians will continue to fight against opioid misuse, overdose, and death. A lot of this legislation will focus on the use of the mandated prescription drug monitoring program (PDMP), better physician education, substance-use disorder treatment, and guidelines or limitations on the prescription of controlled substances.

As has been previously done, many states will focus on PDMPs. Additionally, states will keep considering proposals that advocate for increased access to naloxone. They will also go after stronger Good Samaritan policies for those who assist someone experiencing an overdose.

#3: Provider Networks

Out-of-network care and network adequacy will continue to be major issues in 2017, as networks narrow and patients find themselves footing more bills out of pocket. Physicians are talking to key stakeholders all over the country about offering quality, affordable care to patients while still staying eligible for fair contract negotiations.

There are more than two dozen state medical societies that will address out-of-network billing this year, specifically within the hospital setting. And there are nearly the same number of states considering proposals to address the adequacy of these provider networks.

MBM Supports Physicians

Because most physicians are working to settle legislative concerns and remain focused on the clinical side of healthcare, they hardly have time to worry about billing and coding. That’s where Medical Business Management comes in – to keep physician focus on the patients and not the paperwork. Contact us today for more information!

Financial Incentives Could Be Driving Increased GI Endoscopy Anesthesia Monitoring

anesthesia monitoring

Monitored anesthesia care in routine GI endoscopy has increased within the VHA, but remains low outside of it. This statistic was revealed in a research letter published in JAMA Internal Medicine.

In the letter, Joel H. Rubenstein, MD, MSc, of the department of Veterans Affairs, VA Ann Arbor Healthcare System, and the department of internal medicine at University of Michigan Health System, and his colleagues, stated: “While our results demonstrate that [monitored anesthesia care (MAC)] use did indeed increase in the VHA over the study period, the overall rate of MAC use in the VHA is substantially lower than that observed in fee-for-service environments, further supporting the existence of prominent financial drivers in the growing use outside the VHA.”

The Ins and Outs of Monitored Anesthesia Care

MAC requires an anesthesiology professional and, typically, is done using propofol. Compared with endoscopist-directed sedation that uses short-acting opioids and benzodiazepines, propofol leads to deeper sedation.

According to previous research, more than 50 percent of MAC use occurs in low-risk patients who are having routine endoscopic procedures done, in spite of current guideline recommendations stating that MAC isn’t a cost-effective option for these patients. For that reason, Rubenstein and his colleagues examined MAC use within the VHA in order to have a fuller understanding of the motivation behind increased MAC use.

The Study

Together with his colleagues, Rubenstein conducted a retrospective cohort study of over 2 million veterans who had undergone more than 3.5 million outpatient esophagogastroduodenoscopies (EGD) or colonoscopies at a VHA facility. The time frame was from fiscal year 2000 through 2013, the mean age was 62.8 years, and 94.7% of the veterans were men.

MAC use more than doubled from 4% in fiscal year 2000 to 9.3% in 2013, and began a steady increase in 2008.

In fiscal year 2000, the median facility use of MAC was 0.11% vs. 3.52% in 2013. This varied widely from one facility to the next, especially once the study period was coming to an end.

Rubenstein and colleagues wrote that aside from financial incentives, this increase in MAC use may have been driven by “changes in patient characteristics, such as increased veteran comorbidities or use of prescription opioids (which may confer intolerance to standard sedatives), [and] organizational factors influencing health care delivery, including practice culture, patient preference for MAC, and increased availability of MAC in the VHA.”

They went on to say: “Understanding the presence and degree of inappropriate use of MAC inside and outside the VHA will help promote efficient use of resources and ensure delivery of high-value care.”

The Continuing Case for Bundled Care

The findings of this study support the utilization of bundled payments as a tool to reduce the use of low-value services. This conclusion comes from a related letter by Lee A. Fleisher, MD, of the Leonard Davis Institute of Healthcare Economics at the University of Pennsylvania Perelman School of Medicine in Philadelphia.

In this letter, Fleisher states: “Our first obligation to our veterans is to ensure that they are truly getting the best care and are satisfied with the care. Once that is ensured, and if the current findings simply reflect financial drivers on current practice, then the present article adds to the growing recommendations that bundled care for endoscopy has the potential to lead to delivering the best value: optimal care at the least cost.”

He went on to say that “If gastroenterologists, anesthesiologists, and facilities receive a set fee for the endoscopy procedure and the anesthesia and/or sedation services, then the incentive to provide anesthesia, in situations in which it is not needed, will be eliminated. However, to achieve the goal of getting the most value for our health care dollars, we need a better understanding of the value of anesthesiology vs. moderate sedation for performing endoscopy.”

MBM Can Help with Anesthesia Billing

Here at MBM, anesthesia billing is one of our specialties. If you would like to free up your practice from the burden of paperwork, billing, and coding, contact us today!

It’s National CRNA Week!

From January 22 to 28, 2017, the American Association of Nurse Anesthetists (AANA) is sponsoring National CRNA Week as a way to honor nurse anesthetists. Learn more with Medical Business Management!

What Does a CRNA Do?

Most people don’t really know what a nurse anesthetist does. In general, people think that a nurse anesthetist puts them to sleep, walks out of the room, and then returns to wake up the patient. But the reality is much more than that.

CRNAs are with the patient at all times, from the first greeting all the way through the entire procedure and when they wake up. It is truly a job like no other – and it’s o

ne of the most misunderstood jobs around.

Even so, nurse anesthetists seem to be happy with their careers. The recently-released 2017 U.S. News and World Report Best Jobs list, the job of nurse anesthetist ranked fifth on best health care jobs, and sixth on the best jobs overall.

A Personal Job

Because they are present through the entire procedure, nurse anesthetists can monitor all of the patient’s reactions and behavior. That level of interaction before the anesthesia is administered allows nurse anesthetists to build trust and familiarize themselves with the patient as a person, which makes it a very personal job – especially in the medical field, which can sometimes feel a little impersonal.

One of the reasons CRNAs love their jobs is because they can work with people from the time they are born until they die. They work with people of all ages, and so they must understand how the human body reacts to anesthesia at each age and under a wide range of health conditions.

MBM Loves CRNAs!

Here at Medical Business Management, we’re dedicated to serving CRNAs and helping them do their jobs better by taking care of their coding and billing needs. If you, or a CRNA you know, could benefit from our anesthesia billing services, contact us and let us know. Happy National CRNA Week!

 

New VA Rule Declines Full Practice Authority for CRNAs

new va rulenew va ruleAfter a tense period of debate over the new provider regulations by the Department of Veterans Affairs, on Dec. 14, those regulations were finally amended to allow full practice authority to APRNs employed at VA hospitals.

The pain point? CRNAs weren’t included in that ruling.

According to the final rule, certified nurse midwives, nurse practitioners, and clinical nurse specialists will be able to practice to the full extent of their training and education. But certified registered nurse anesthetists will not – and that exclusion has caused something of an uproar.

Why Are CRNAs Excluded?

The VA has stated in a news release that, because it does not have immediate, wide-ranging patient access challenges to anesthesia care throughout its health system, it has chosen not to include CRNAs as one of the roles that will receive full practice authority.

Obviously, this has left some in the nursing field with a bone to pick.

AANA President Cheryl Nimmo, DNP, MSHSA, CRNA, has expressed her disappointment with the VA’s decision because now “veterans will continue to deal with long wait times for needed healthcare procedures that require anesthesia services.”

And the solutions to that problem – highly qualified CRNAs – are being blocked from achieving their highest standard of practice because of this exclusion, which, in turn, affects veterans.

No Issues with Anesthesia Care?

While the VA claims there haven’t been widespread issues with anesthesia care, the VHA Independent Assessment tells another story. In 2015, they identified numerous problems in the anesthesia sector, such as:

  •      Cardiovascular surgery delays due to a lack of anesthesia support
  •      A rise in demand for procedures that require anesthesia outside of the OR
  •      Compared to the private sector, a sluggish production of colonoscopy services

Clearly, these things are issues – and they could be resolved if full practice authority had been granted to CRNAs.

Statements from AACN and ANA

The American Association of Colleges of Nursing (AACN) has acknowledged that the full practice authority granted to 3 APRN roles is progress. However, they are pushing for the policy to include CRNAS as well.

“AACN believes the full cadre of clinicians will not be maximized within the VHA if CRNAs are excluded,” the organization stated via news release. “AACN appreciates the opportunity that the VA has provided to allow for an additional 30-day comment period on full practice authority for CRNAs. We stand firm in our view that CRNAs would increase access, and will submit additional comments to the VA in collaboration with our colleagues in the community.”

These thoughts were reflected in an official statement by Pamela F. Cipriano, PhD, RN, NEA-BC, FAAN, president of the American Nurses Association.

“The American Nurses Association is pleased with the VA’s final rule allowing APRNs to practice to the full extent of their education and training,” she said. “However, ANA is concerned with the final rule’s exclusion of CRNAs, which is solely based on the VA’s belief that there is no evidence of a shortage of anesthesiologists impacting access to care. We join with our colleagues in continuing to advocate for CRNAs to have full practice authority within the VA health care system.”

Fighting for Change in the Future

Many professional nursing organizations are planning to continue advocating for the inclusion of CRNAs in the ruling. Until the policy is changed, however, it’s likely that veterans will continue waiting too long for medically necessary procedures that involve anesthesia – and since caring for veterans is the focus of the VA, this seems like a significant oversight on the organization’s part.

The ABCs of Anesthesia Billing

anesthesia billing

Anesthesia billing can be hard to understand — and even harder to keep up with. From revenue cycle management to coding, it’s almost inevitable that something will fall through the cracks (unless you hire a third-party company to handle it for you, of course).

Here, we’ve broken down the anesthesia billing process into three components to give you an idea of what it looks like at its most basic level. However, it’s important to note that this is not an exhaustive guide to anesthesia billing; it’s simply a starting point.

With that said, let’s take a look at the ABCs of anesthesia billing.  

A: Add It Up

Anesthesia practices determine how much they should get paid by using a formula, so knowing the formula is a great place to start:

Base Units + Time Units + Modifying Units = Total Amount Billed

Base units are the first component to the formula. For most surgical procedures, a basic value is assigned by the ASA depending on the difficulty of the surgical procedure. The value for all usual anesthesia services is included in this, except the time actually spent in anesthesia care, along with any modifiers.

B: Beginning Time

Time is the second component to the formula. It’s essential to know the exact moment you should start billing for anesthesia services because you’ll have to report it accurately and make sure it matches across all reports, charts, and bills.

According to the Medicare Anesthesia Manual, “Anesthesia time begins when the anesthesia provider starts to prepare the patient for the procedure and remains one to one with the

patient. Normally, this service takes place in the operating room, but in some cases, preparation may begin in another location (i.e., holding area). Anesthesia time is a continuous time period from the start of anesthesia to the end of an anesthesia service, when the patient is released to recovery.” Your start time should be consistently reported across all documents and bills.

Of course, you also need to keep up with anesthesia start time and stop time, and remember that any break in anesthesia time cannot be billed.

C: Consider Modifiers

Modifiers are the third component to the formula. Your modifiers are extremely important, as they communicate everything from the condition of the patient to what type of anesthesia service the patient received.

The appropriate modifiers must be applied to claims in order to ensure the correct reimbursement amount. Obviously, if this is not done correctly, things can get complicated very quickly.

Ready to Outsource Your Anesthesia Billing?

MBM understands all the ins and outs of the anesthesia billing process. When it comes to coding, revenue cycle management, and A/R, it pays to have an experienced third-party service provider like MBM handle everything for you so that you can focus on your patients and your practice. Ready to talk to us about managing your billing process? Contact us today!

The ABCs of Calculating Anesthesia Time Units

It’s essential to stay vigilant when it comes to calculating anesthesia time units. Not properly doing so can result in delayed or denied claims, decreased revenue, and audits – which can have a negative impact on your practice’s reputation. Take a moment to look over this guide on the basics of calculating anesthesia time units […]

The ABCs of Physical Status Modifiers

Accuracy is essential when it comes to physical status modifiers in the anesthesiology field, and as of January 2016, the ASA Physical Status Classification System (modifiers P1-P6) includes examples to assist in choosing the appropriate modifier. The original version was published in 1941 by Meyer Saklad, and then by ASA in a booklet for the […]

The ABCs of MAC Anesthesia

You may have heard about MAC anesthesia, or maybe you know someone who experienced this type of sedation during surgery – but what exactly is it, and how does it differ from general anesthesia? These are great questions, and they concern a lot of people – especially those who claim they’ve been awake during surgery. […]

The ABCs of CPT Modifiers

Because of the complexity of medical procedures and services, additional information is often necessary when coding. This information typically comes in the form of what’s called a CPT modifier, which describes how many procedures were performed, why they were necessary, where they were performed on the body, how many surgeons were involved in the operation, […]

Financial Incentives Could Be Driving Increased GI Endoscopy Anesthesia Monitoring

Monitored anesthesia care in routine GI endoscopy has increased within the VHA, but remains low outside of it. This statistic was revealed in a research letter published in JAMA Internal Medicine. In the letter, Joel H. Rubenstein, MD, MSc, of the department of Veterans Affairs, VA Ann Arbor Healthcare System, and the department of internal […]

It’s National CRNA Week!

From January 22 to 28, 2017, the American Association of Nurse Anesthetists (AANA) is sponsoring National CRNA Week as a way to honor nurse anesthetists. Learn more with Medical Business Management! What Does a CRNA Do? Most people don’t really know what a nurse anesthetist does. In general, people think that a nurse anesthetist puts […]

The ABCs of Anesthesia Billing

Anesthesia billing can be hard to understand — and even harder to keep up with. From revenue cycle management to coding, it’s almost inevitable that something will fall through the cracks (unless you hire a third-party company to handle it for you, of course). Here, we’ve broken down the anesthesia billing process into three components […]