Revenue Cycle Insider

Dot your i's and cross your t’s to shore up your records.

Complete and correct documentation is essential for compliant billing and accurate reimbursement not only in anesthesia, but in all practice types. Deficiencies can lead to incorrect reimbursement (whether it be overpayment or underpayment), denials, and potential exposure to a payer audit.

Find out what you may be missing or risking if your documentation isn’t up to snuff.

Try to Prevent Unclear Medical Direction

While this list is not exhaustive, here are some common deficiencies found in anesthesia billing and coding audits:

• The documentation may fail to properly identify the providers involved or records are not signed by providers.
• Incomplete or missing documentation of all seven required medical direction elements. These were put in place by the 1982 Tax Equity and Fiscal Responsibility Act (TEFRA) and must be met by the anesthesiologist to bill medical direction. Here are the seven elements:
  1. Perform a pre-anesthetic exam and evaluation.
  2. Prescribe the anesthesia plan.
  3. Participate in the most demanding procedures in the anesthesia plan, including induction and emergence.
  4. Ensure a qualified individual performs any procedures in the anesthesia plan that the anesthesiologist does not personally perform, such as another anesthesiologist, certified registered nurse anesthetist (CRNA), or anesthesiologist assistant (AA), if practicing in a state that allows AAs.
  5. Monitor anesthesia administration at frequent intervals.
  6. Remain physically present for all key and critical portions of the case and be available for emergencies.
  7. Provide post-anesthesia care as needed.        
• Inconsistencies between documentation and modifiers billed. For example, the practice bills the anesthesiologist claim with modifier QK (Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals), and the CRNA claim with QX (CRNA service: with medical direction by a physician), but the documentation does not support that the case was medically directed.

Look for Inadequate Documentation of Separately Reported Services

While certain procedures, such as intubations, are included in the anesthesia base unit value, there are services that you can report in addition to the anesthesia service. Arterial lines, central venous lines, and postoperative blocks requested by the surgeon for postoperative pain are just a few examples of services that you can bill separately.

A complete procedure note should be included with the anesthesia record when you bill these procedures separately. Another notable deficiency is an unclear distinction between the primary anesthesia service and a separately reportable service. For example, a patient undergoes a rotator cuff repair and has an interscalene block, but the records do not indicate if the interscalene block is the primary form of anesthesia or requested by the surgeon for postoperative pain. If the block is the primary form of anesthesia, you cannot bill it separately; but if it is for postoperative pain and is documented correctly, then you can bill for it separately.

Check on Incomplete or Inconsistent Anesthesia Time Documentation

There are several ways that time could potentially be incomplete or inconsistent. The time could be missing, or the time entries do not align with the intraoperative record or other documentation.

Another potential documentation deficiency is if there is a large gap between the anesthesia start time and the procedure start time. There are many reasons this could occur, such as equipment or instrument issues, surgeon delays, or preoperative tasks that can cause delays. If this is the case, the reason for the delay should be noted in the anesthesia record.

Note Any Discrepancies Between Anesthesia and Operative Reports

The surgeon’s operative report provides detail that the anesthesia record may not, and auditors often request it to get a clear picture of the case. Coders need certain information — such as whether a procedure is on the upper or lower abdomen, how deep a debridement goes, or if spinal instrumentation is used — to accurately code a case. However, this is not always included in the anesthesia record.

There may also be discrepancies in the procedure listed on the anesthesia record and the operative report. This could be the result of the procedure being changed and only the planned procedure is listed on the anesthesia record. Anesthesia coding should be supported by the procedure performed rather than the procedure scheduled.

To reduce documentation deficiencies, develop standardized anesthesia records, documentation templates, and checklists that include all required elements to ensure accurate billing and coding. The only thing constant in medical billing is change, so provide recurring education for coders and billing staff, as well as providers. This can be an opportunity to address any deficiencies that have been found during an audit and also inform staff and providers of any upcoming changes that could impact documentation. Designate a member of the billing staff or hire an outside auditor to conduct regular audits. Use the audit results to educate billers and providers on any documentation deficiencies found and develop a plan to correct those deficiencies.

Accurate documentation is fundamental to complaint billing. Auditing requires more than just reviewing the coding; it encompasses making sure the record supports everything that was billed and identifying any documentation that might be lacking. Anesthesia practices can feel confident they are sending out claims that are both accurate and compliant, while receiving the most reimbursement allowed, by addressing deficiencies through provider and staff education, standardized processes, and ongoing auditing.

Julie McDaniel, MHA, CPC, CANPC, Contributing Writer