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!

Creating a Better Reconciliation Process for Anesthesiology Billing

anesthesiology billing

When it comes to successful anesthesiology billing, it’s important to collect every bit of revenue possible. Even one missed or overlooked case can result in losing hundreds – if not thousands – of dollars of revenue. And given the high caseload many anesthesiologists face, overlooking a case now and then happens more than you’d think.

Avoiding lost revenue is why practices create reconciliation processes. Here, we’ll discuss how you can create a better reconciliation process to maximize revenue collection.

Common Reconciliation Problems

One problem that causes difficulty with maximizing revenue is how records are stored.

Most practices use a combination of paper and electronic recording. In a practice where there is just one patient and one insurer, this isn’t that big of a problem. But that situation doesn’t exist. In reality, practices have potentially hundreds of patients with several different insurers.

As a result, mixed record-keeping can cause difficulty – and much of it comes from having a paper-based billing process.

Another problem comes with lacking a standardized process to make sure what happens in the OR is communicated properly to the billing team – and is then communicated to the insurer. This is like playing the telephone game. Whenever multiple groups are involved, missteps can be made.

Finally, there is usually inadequate software – or sometimes no software at all – to keep track of patient care from the beginning of care through the final payment from the insurer.

Tips for a Better Process

Solving these problems isn’t impossible. There are steps a practice can take to incorporate reconciliation into an anesthesiology billing process.

Standardize with Electronic Billing

Moving to electronic billing can alleviate inconsistency and misplaced paperwork. It’s easier to track and document what has and hasn’t been paid if you eschew paper and move to electronic records. While it’s probably not possible to become completely paperless, most practices can greatly reduce their paper usage by going electronic.

Reconcile Daily

Reconciliation – especially with cash payments – isn’t something you can do on a monthly basis, or even a weekly basis. It has to happen daily.

Create daily reconciliation processes that handle: 1.) payments from that day, then 2.) payments outstanding from the previous day. On a weekly basis, it’s appropriate to look at any outstanding payments from the previous week (and do the same on a monthly basis). Daily reconciliation will help you keep ahead of the curve so that nothing slips through the cracks.

Keep Track of Aging Claims

Some claims can take up to a year to be paid by a payer. And generally speaking, the older a claim, the more unlikely it is that it’ll be paid – the more likely it is that the practice will forget about it. Be aware of aging claims. Develop a system to monitor claims as they age from the date they are filed, from 30 days, 60 days, 90 days, 120 days, and beyond. Take action steps at each of these marks to at least stay aware of what is owed.

Outsource Anesthesiology Billing

Developing a reconciliation process can be difficult if your practice hasn’t previously done so. Outsourcing your anesthesiology billing to a third-party provider can alleviate a lot of the burden of having to keep track of often-complex billing – and can decrease your A/R.

Navigating Three Key Compliance Issues for Anesthesiologists

anesthesia billing specialist

Running an anesthesia practice means complying with a labyrinth of rules and regulations. There are three related compliance issues that many anesthesiologists have a difficult time abiding by, and all of them have to do with payment.

These compliance issues are:

  • Professional courtesy fee waivers
  • Co-payment waivers
  • Discounts for cash payments

Many practices encounter these issues on a semi-regular to regular basis, but may run afoul of generally-accepted legal principles and practices without knowing it.

To clear up any confusion, and to ensure proper compliance, here are the general guidelines for handling each of these situations.

Professional Courtesy

Professional courtesy is broadly defined as waiving payment from other physicians and/or their family members and employees. The Department of Health and Human Services’ Office of the Inspector General (OIG) covers this and other compliance issues in its Compliance Program for Individual and Small Group Physician Practices. According to this document, there are two broad considerations for whether or not professional courtesy is in violation:

  • How the provider selects the recipients of the professional courtesy;
  • How the professional courtesy is offered to the recipients.

Recipients generally can’t be selected because the provider thinks they’ll be a good source of referrals. This could run afoul of an anti-kickback statute that prevents providers from giving something of value in order to get business involving federal health care programs.

(Note that this may not apply to non-federal programs. Providing courtesy for those who aren’t in a position to generate Medicare/Medicaid referrals is generally allowed, as rare as that situation may be.)

The practical way to comply is to pre-determine groups of people to whom you will offer professional courtesy. In other words, don’t limit courtesy to just those who could be good referral sources. Instead, offer courtesy to any physician and their families/employees, regardless of their ability to send over business. Avoid the impression of impropriety by being more permissive and less restrictive.

Co-Pay Waivers

Waiving the co-pay (also known as “insurance only”) is similar to professional courtesy in that both involve reducing or eliminating the cost of a service to the patient. However, one key difference is this: waiving co-pays is almost always illegal.

Why is this the case? OIG doesn’t want practices to get into the habit of attracting more Medicare patients by waiving co-pays because doing so encourages excessive use of Medicare services by the general population. Additionally, OIG views doing so as fraudulent against the Federal Government because it misrepresents the practice’s normal fee.

It’s not just the Federal Government that views co-pay waivers as fraud; many states have gotten in on the action, too. Additionally, most health plans frown upon or outright forbid co-pay waivers.

Note that waiving co-pays for fellow physicians and their families isn’t illegal in the eyes of OIG, but when it comes to Medicare patients, it is illegal. In general, it’s best to never waive co-pays to avoid any semblance of impropriety.

You can learn more about the differences between co-pays and courtesy here.

Cash Payment Discounts

Finally, practices sometimes offer discounts for cash payments to patients, mainly to avoid costs associated with getting payment from insurance companies (as well as the uncertainty that often comes with dealing with insurers).

It’s not illegal to bypass insurance. What is illegal, however, is offering discounts and then billing the insurer anyway. This usually happens unintentionally due to poor record-keeping and administrative oversight (although some providers undoubtedly attempt to break the law and commit fraud).

When offering discounts, it’s important to always check with the terms and negotiated rates of your health plan contracts. You don’t want to undercut your own rates, or be in violation of your contract. Plus, you want to make sure each instance of offering a discount is carefully tracked, so you don’t offer a discount for a cash payment to a patient and then turn around and bill the insurer. Protect yourself by putting a plan in writing and abiding by it rigorously.

Understanding these compliance issues from a broad perspective is relatively simple, but comprehending the fine details and legal implications is a bit more difficult. If you have further questions, contact an anesthesia billing specialist to learn more and stay in compliance.

Understanding – and Abiding By – Anesthesia Documentation Requirements


anesthesia documentation

Compliance, for an anesthesia practice, is quite different from other medical practices and specialties – and can even differ within the anesthesia field.

Because so much depends on proper compliance, practices need to understand what is required of them when it comes to complying with rigorous documentation requirements. However, many providers – even those with decades of experience – have trouble keeping up with the myriad documentation standards out there. This is mostly because documentation guidelines change regularly, so what was in effect five years ago – or even a year ago – may not be in place today.

Here, we’ll provide a general overview of anesthesia documentation requirements. Note that you can get a more thorough understanding of all requirements by contacting a billing and coding specialist that works with anesthesia practices.

Examining the Basic Requirements

National standards for documentation come from the National Committee for Quality Assurance (NCQA), which publishes the Guidelines for Medical Record Documentation. In the guidelines, there are 21 separate elements. Not all of these apply to anesthesia practices.

The ones that do apply specify that each page in a patient’s record must contain the patient’s ID number or name. Additionally, all medical record entries must have the author’s ID, which can come in the form of initials, an electronic ID, or a handwritten signature. Finally, the record must be legible to others who read it, beyond the writer.

There are other guidelines available, such as the ones from the American Association of Nurse Anesthetists (AANA). Perhaps the most commonly used guidelines, other than NCQA, come from the American Society of Anesthesiologists (ASA). They don’t publish documentation guidelines per se, but do have several general guidelines that can be found here.  

Documentation Standards for Anesthesia Care

When we get into more specific guidelines (using those published by ASA), we break down the standards into three areas: pre-anesthesia care, intra-operative care, and post-operative care.

Pre-Anesthesia Care

Before anesthesia is administered, CMS mandates that pre-anesthesia documentation be signed by a medical directing anesthesiologist. Additionally, there are a few things that need to happen with a patient that must be documented, including:

  • Discussing the patient’s medical history, including any prior experiences with anesthesia
  • Examining a patient’s physical health for risk management
  • Ordering any tests and consultations that are necessary prior to care
  • Ordering any medications for pre-operative care
  • Obtaining and documenting consent from the patient before care is administered

As mentioned, providers must be careful to record that all steps were taken prior to the delivery of care.

Intra-Operative Care

During the administration of care, there are two standards. The first standard, as dictated by ASA, is that qualified anesthesia personnel need to be present in the room while all general and regional anesthetic care is delivered (including monitored anesthesia care).

The second standard is that qualified personnel should, during the administration of care, constantly monitor a patient’s circulation, temperature, ventilation, and oxygenation.

As with anything, adherence to these standards should be documented.

Post-Operative Care

Finally, standards for post-operative care stipulate that patients should be admitted to a post-anesthesia care unit (PACU) or another equivalent area, unless ordered to do otherwise by the anesthesia provider. The provider is responsible for the patient until a PACU can take over.

How Auditors Review Documentation

Documentation becomes critically important whenever a practice faces an audit from an auditor.

Auditors check documents to determine, among other things, that the anesthesia provider continuously monitored the patient and that the anesthesia time was properly documented. For example, auditors want to see notation that the provider checked the patient’s vitals once every five minutes at the very least. Additionally, auditors will check your recorded anesthesia time against records from the PACU and operating room. They may not match exactly, but they need to be very similar.

Auditors also review records for use of anesthesia modifiers. Use of modifiers, and medical direction in general, is covered by the Medicare Claims Processing Manual from CMS, which defines medical direction as: performing a pre-care evaluation, prescribing an anesthesia plan, personally participating in the most difficult portions of care, making sure that all procedures not personally administered are done so by a qualified anesthetist, monitoring anesthesia administration at regular intervals, staying present and available, and providing post-anesthesia care.

There are allowed exceptions, which are covered in more detail in the manual.

Ensuring Compliance with Regular Record Review

Staying compliant means constantly reviewing records to ensure they are complete and accurate, as well as conforming to standards. Internal review processes are exceptionally useful, provided that the reviewer and the record creator are two different people.

Compliance is crucial. Regular reviews from internal and external sources are strongly recommended. Every practice needs a formal plan for compliance, with written processes and standards to make sure all claims abide by standards established by CMS and insurers, and to ensure documents are correct.

Consult with a billing specialist to learn more about guidelines and standards for claim documentation and how to fully comply with them.

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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 […]

Navigating Three Key Compliance Issues for Anesthesiologists

Running an anesthesia practice means complying with a labyrinth of rules and regulations. There are three related compliance issues that many anesthesiologists have a difficult time abiding by, and all of them have to do with payment. These compliance issues are: Professional courtesy fee waivers Co-payment waivers Discounts for cash payments Many practices encounter these […]

Understanding – and Abiding By – Anesthesia Documentation Requirements

Compliance, for an anesthesia practice, is quite different from other medical practices and specialties – and can even differ within the anesthesia field. Because so much depends on proper compliance, practices need to understand what is required of them when it comes to complying with rigorous documentation requirements. However, many providers – even those with […]