Anesthesia RCM Specialty Challenges
By Joe Laden, Vice President Client Management
Anesthesia billing and coding is an array of unique and complex specialty requirements not found in other medical specialties. Though many billing and coding companies claim experience and expertise in anesthesia billing, the truth, when compared against actual performance, tells a different story. Given the unique aspects of anesthesia billing and coding, it is somewhat remarkable that in RFPs and RFIs, not all of the required billing, coding, and data analytics are addressed.
Given the complexity of anesthesia, I’ve put together in one place all of the elements that anesthesia practices should consider when evaluating a billing and coding company. We all know these, but from time-to-time things are missed in a rush to make decisions. By referring to all the complex requirements of anesthesia at the same time, you can ensure that you’re selecting the right anesthesia billing and coding company with capability in all the following areas.
Unique system for Billing and Reimbursement
Anesthesia has a separate set of CPT codes that are different from the CPT codes of other specialties. Anesthesia time-based administration is billed under the type of service code 7. Each anesthesia CPT code has an associated number of base units, and these base units are combined with time units to produce the amount billed for anesthesia. Time units are usually one unit per 15 minutes of anesthesia administration time, but some payers allow 10-minute units or 12-minute units.
Anesthesia coding Complexities
Coding for anesthesia requires first determining the CPT code for the surgical procedure for which anesthesia is administered and then using a cross-walk system to map the surgical CPT code to an anesthesia CPT code. Mapping is not necessarily 1:1 and requires an experienced anesthesia coding specialist to do so.
Anesthesia Rules for Medical Direction and Supervision
Medicare has separate sections in the carrier payment manual for anesthesia. (Chapter 12 Sections 50 and 140.3). In these sections, Medicare details the billing rules for cases that are attended by a combination of anesthesiologists, CRNAs, CAAs, and anesthesiology residents. Anesthesia cases are billed and reimbursed differently depending on the combination of providers on each case. There are six modifiers used for this purpose and four other modifiers unique to anesthesia.
When multiple providers attend an anesthesia case, a complex system called “concurrency checking” must be used to assure that there are no minute-by-minute conflicts between the providers and to determine the maximum number of medically-directed or supervised CRNAs or CAAs simultaneously working for every minute during the case.
ASA Physical Status Classification System
The ASA Physical Status Classification System is used to designate the physical status of the patient as it applies to the administration of anesthesia. Anesthesia units can be billed for ASA Physical Status P3-P5. These codes are added to the modifier field on the claim form.
Anesthesia Qualifying Circumstances
There are Qualifying Circumstances for anesthesia that can be billed separately. These are unique to anesthesia and are 99100, 99116, 99135 and 99140. Not all-payers pay for all of these codes, and some payers require that some of these coded not be billed. For example, the “extremities of age” code may not be billed to Medicare.
Obstetrical Anesthesia Billing
Unlike operative anesthesia services, there is no single, widely accepted method of accounting for time for neuraxial labor anesthesia services.
Each government and commercial payer can have individual requirements for billing these services usually based on the duration of the service or contact time with the patient.
Methods of payment vary and can be by flat rate or based on time with maximum time limitations.
Because of the duration of a labor epidural, which can be as much as 24 hours, most anesthesia practices “cap” the billing charges to a reasonable maximum amount to avoid a large “surprise” bill to the patient.
Anesthesia practices use the EHR systems provided by the facilities, so the billing entity must provide electronic medical record and demographic interfaces at each of the facilities covered by the anesthesia practice. Most anesthesia practices work at multiple facilities, including those that are on manual records system.
Provider/Payer Enrollment Issues
Many anesthesia practices use locum and occasional providers with high turnover rates resulting in credentialing challenges to have providers enrolled with payers before their start of work.
Anesthesia bills on a time-based system requiring keeping track of every provider (MD, CRNA, etc.) who works on each case. It is not uncommon to have two anesthesiologists and three CRNAs/CAAs providing services on a single anesthesia case. Each provider’s time must be tracked to the minute.
Non-Anesthesia Procedures Billed with Anesthesia
In addition to time-based billing for an anesthesia case, during the case, anesthesia providers can also bill for the placement of post-operative pain control procedures and the insertion of arterial lines. These additional surgical procedures must adhere to the standard CCI edits and use standard modifier codes.
Monitored Anesthesia Care
Most methods of anesthesia (general, regional, spinal, TIVA) are paid the same. However, monitored anesthesia care is submitted with the QS modifier and is treated differently by payers. Some payers reject this type of anesthesia if it is not submitted with certain qualifying diagnosis codes. Some payers handle the deductible differently for monitored anesthesia care depending on the anesthesia CPT code submitted.
Rounding of time units
Anesthesia claims are submitted with the duration of anesthesia in minutes. Payers convert the anesthesia minutes to anesthesia time units but vary in the way time units are calculated. Some payers round time units up to the next whole unit while others calculate to the nearest tenth of a unit.
Fee Checking for Payer Contract Compliance
Because each payer can have its own rules for calculating and reimbursing units as well as calculating the payment for the different modes of medical direction and supervision, checking of fees paid must take into account all-payer variations. Also, some anesthesia charges are time-based and some are not. Some payers pay for qualifying anesthesia circumstance codes and for ASA physician status and some do not. There is no standard for reimbursing OB anesthesia for labor and delivery. Payer payment rules vary by state. For Medicaid, each of the various state Medicaid MCOs can have slightly different billing and payment rules.
Due to these intricacies, the billing system program that checks fees paid by the government and contracted commercial payers must check each line of each claim payment against the billing and payment rules required by each payer.
Due to the unique characteristics of anesthesia billing, internal and external auditing requires specialized auditors with anesthesia auditing experience. Auditing includes checking for medical direction and modifier compliance as well as for CPT and diagnosis coding accuracy.
Chronic Pain Clinic
In addition to operating room anesthesia, most anesthesia practices staff a chronic pain clinic. Coding and billing for chronic pain are similar to medical/surgical billing. Specialized, non-anesthesia coders may be needed for the pain clinic.
Patients may call in advance of surgery for an estimate of their anesthesia bill. Because anesthesia billing is time-based and the exact length of surgery is unknown, an accurate estimate may be difficult to calculate. A good estimate is needed if the patient wants to prepay cosmetic or other surgical anesthesia not covered by insurance.
Reporting and Data Mining
Because anesthesia billing is mostly time-based and because multiple providers can be billed for different segments of a case – individually or simultaneously -many time and other elements must be stored for each case. Reporting needs to be done with and without time factors, including reporting on base units and time units. Each case will have an anesthesia CPT code and a surgical CPT code. Pain clinic reporting differs from surgical anesthesia reporting.
Consequently, reporting for anesthesia practices requires a robust data management system with anesthesia-specific billing and management reports.
The reporting system must be able to produce anesthesia production reports that are time-based and can show time utilization by the facility, operating room, and provider.
In this comprehensive listing of anesthesia billing requirements developed from my experience in managing large anesthesia practices, as well as presenting nationally on this topic, you should find it a useful evaluation tool, and a reminder of what an anesthesia billing and coding company needs to deliver to your practice daily.
Joe Laden is Vice President of Client Management, AdvantEdge Healthcare Solutions, and a nationally recognized anesthesia expert and speaker, working with anesthesia practices across the country to improve their billing and coding operations.
AdvantEdge Healthcare Solutions is a national top 10 medical billing company that provides billing, coding, and revenue cycle management solutions for anesthesia practices since 1989. If you have questions about how AdvantEdge can improve your anesthesia billing and coding to collect every dollar that you’re legally and ethically entitled, please call us at 877-501-1611 or email [email protected].