For many years, the defined start and end times an anesthesia provider can bill for have been set, yet many anesthesiologists and nurse anesthetists still experience confusion on this important aspect of billing. Granted, the rules are not exactly black and white, but they do give a fair amount of guidance for anesthesia providers.
Historically, the anesthesia specialty has always constituted a small percentage of overall healthcare costs. In anesthesia, we have seen relatively minimal change and less scrutiny than other specialties. However, the amount of regulatory audits have begun to increase and we have seen a much more targeted effort in the Recovery Audit Contractors (RAC) program. Compliance is becoming a bigger and more important issue for all anesthesia groups, therefore, we hope this article will provide clarity for those who are unsure of what to do.
A common question we hear is, “does anesthesia start time begin when you enter the operating room?” The answer: It can, but does not have to be. Both Centers for Medicare & Medicaid Services (CMS) and Current Procedural Terminology (CMT) definitions of anesthesia time are very similar. The CPT defines anesthesia time as beginning when the anesthesiologist begins to prepare the patient for the induction of anesthesia in the operating room or in an equivalent area. It also clarifies that time is started from the moment the anesthesia provider places monitors, starts the IV, and begins to administer preoperative sedation or other medications.
Another common question asked is, ”Is the time spent on the anesthesia preoperative included in the base units, or do I charge for the time spent reviewing the patients chart?” The preoperative evaluation is part of the base units. Anesthesia providers cannot charge any time to do a routine anesthesia preoperative evaluation.
Anesthesia time is defined as the continuous presence of an anesthesia provider. Anesthesia time ends when the anesthesia provider is no longer in personal attendance and the patient is placed safely under the postoperative supervision of a nurse in the post-anesthesia recovery unit.
Finally, it is very important to be accurate with your times. Never round your times up to nearest five-minute increment. A practice could be found noncompliant if more than twenty percent of the start and stop times are fixed on five-minute intervals. To maintain compliance, simply document the actual time. As government regulators become more aggressive with audits, it becomes increasingly imperative that clinical documentation, coding and claims are audit-proof.
Maintaining audit-ready anesthesia departments is a top priority for DPI. We conduct internal audits for our clients and ensure our anesthesia providers are knowledgeable of the latest rules and regulations. Contact us today if you have questions about compliance for your anesthesia department.