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Chart "Tools & Tips"

NOTE: **These are general documentation guidelines, please review payer Local Coverage Determinations (LCDs) or contact our billing and coding specialists directly for specific documentation questions.  Appropriate and accurate documentation is crucial to billing compliance, reimbursement, and to avoid any medical legal issues**

Accurate documentation: Accurate documentation and auditing of such, leads to increased billing compliance and maximized reimbursement.

Anesthesia Time

   Start time: When the anesthesia practitioner begins to physically prepare the patient for anesthesia services in the operating room or an equivalent area, including starting IV, placing monitors and preparing the patient for anesthesia.

   End time:  When the anesthesia practitioner transfers care in the PACU to a qualified professional.  If the anesthesia providers' time is extended in the PACU, it is billable, but the anesthesia provider needs to document the circumstances of why they were with the patient longer than is typical.

  Canceled cases:  If a patient is seen and evaluated but the procedure is canceled due to patient condition, prior to the induction of anesthesia, an E&M code can be billed.  Please be sure to document the following:

  • Pre-op evaluation

  • Pre-op physical exam; vital signs at minimum and reason why the case was canceled prior to induction.

  • Time spent on these activities must be a minimum of 30 minutes split between chart/ H&P review and physical exam.

  • Case must not be rescheduled within 48 hours to bill for these services as a separate charge.

  Other considerations for anesthesia time:

  • Enter the exact time, do not round.

  • End time for one case and start time for the next must be at least one minute apart.

  • Local anesthesia is not billable if provided by a non-anesthesia provider.

Pointing Pen and Finger on Document

General Documentation Requirements

  • Have patient identifiers on all chart documents (name, gender, DOB, DOS)

  • Document patient diagnosis, must match surgeons records

  • ASA status; please add any additional qualifiers such as emergent procedure or conditions, unusual positioning or prolonged procedure time.

  • Anesthesia start and stop; document relief start and stop providers, and regional start and stop times all documented separately

  • Service/procedure performed

  • Type of anesthesia provided

  • Patient positioning

  • Discontinuous time documented (if anesthesia time started and had a pause for any reason before resumption of care).

  • Surgeon request is required to be documented for post-op pain management (regional blocks); in addition document start/stop times for block, location and type of block, provider performing procedure and amount and type of medications used.

    • **Blocks/Regional cannot be billed separately if used as part of the anesthetic plan for the surgical procedure** they must be performed and documented as a separate procedure for postoperative pain management with an ordering physician (typically the surgeon) as the referring provider.​

Anesthesiologist Billing for Medical Direction vs. Supervised Rate:

Medicare pays for medical direction of CRNAs at 50% of the reimbursement for the case.  To meet medical direction requirements of two to four concurrent cases, the anesthesiologist must meet the TEFRA rules.  No more than 4 cases (CRNAs) can be medically directed at one time.  An anesthesiologist must document the seven steps, which should be present in the anesthesia record.  Two separate claims need to be filed for medically directed anesthesia procedures (one for the anesthesiologist and one for the CRNA).

1. Performs a preanesthetic examination and evaluation

2. Prescribes the anesthesia plan

3. Personally participates in the most demanding procedures in the anesthesia plan including, if applicable, induction and emergence

4. Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified individual

5. Monitors the course of anesthesia administration at frequent intervals

6. Remains physically present and available for immediate diagnosis and treatment of emergencies; and

7. Provides indicated post-anesthesia care.

CRNAs working as "locums" coverage, must be credentialed and privileged, obtain NPI, and bill for their own services.  Physicians may be paid on a per diem or "fee-for-service" basis, by the regular physician.

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