Y O U R M O N T H L Y
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The Summit Resource is
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specifically for Anesthesia
and Pain Management
providers. Our objective
is to provide you with up
to the minute billing,
coding, and practice rece ntly, it has been generally
accepted in the anesthesia billing
management information. community that auditors would
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“How to bill when you
fail to meet medical
direction documentation
guidelines.”
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A N E S T H E S I A
here is new and important
news regarding how to proper-
ly document your time. Until
not quibble about 5 minutes of
billing prior to entering the OR or
5 minutes spent in the PACU.
However, advice to you about
documenting time has changed
due to a new experience.
Recently, an anesthesia
group in Connecticut had under-
gone a Medicaid audit. In that
audit, the Medicaid auditor took
the position that the PACU time
was not properly documented.
The client had to refund approxi-
mately $30,000 relating to this
and other issues.
What is concerning is that,
despite the fact that the client
had religiously written the anes-
thesia start and anesthesia end
time on the front of the anesthe-
sia record, in a box marketing
“anesthesia end,” the auditor dis-
allowed the end time as not
being independently documented.
Despite the group’s protests
in a meeting with the auditor,
the auditor maintained that,
although he could audit the
start time against the intra-
operative nurse’s “OR in” time,
there was no recordation by the
PACU nurse as to when the
CRNA or anesthesiologist turned
the patient over to the recover y
room nurse and left the PACU.
It was argued that the “anes-
thesia end” time on the front of
the anesthesia record was for
that very purpose, but the audi-
U P D A T E
tor countered that the “anesthe-
sia end” time was not indepen-
dently corroborated; therefore,
it was not acceptable. The audi-
tor stated that the CRNA or
anesthesiologist could have
written down any time he or she
wanted as the “anesthesia end”
time; therefore it was not suffi-
ciently corroborative.
When asked what would
have been acceptable, the audi-
tor stated that the anesthesia
record itself would have to
independently document when
the CRNA or anesthesiologist
left PACU. This could be docu-
mented on the back of the
anesthesia record, in the com-
ment section of the record, or
on the bar graph/timeline of
the record.
While we do not agree with
this view, we try to provide our
clients with advice based on
One of the biggest threats
your anesthesia practice
faces today is Regulator y
Compliance. Summit has
joined with healthcare
attorneys who specialize in
Anesthesia to provide a prac-
tice review tool we
call Vital Signs for
Anesthesiologists. Vital Signs
is an onsite review which
results in a written report
what is actually happening “in
the field”. Accordingly, we rec-
ommend that you revise your
time documentation as follows:
All pre-op meds should be
char ted on the bar
graph/timeline of the anes-
thesia record. If those meds,
such as Versed, are adminis-
tered in the pre-op area,
star t char ting the time line
in the pre-op area, and write
down the Versed administra-
tion at the appropriate time.
Example: if Versed is given
in pre-op area at 0700, but
patient is not brought into
the OR until 0710; star t
charting time on the anes-
thesia record timeline/bar
graph at 0700. At the 0700
line, either write down “pre-
op meds” or put an “X” with
a line “X———“ to signify
the length of time spent with
highlighting your potential
compliance violations and rec-
ommendations for optimizing
your business practices.
If you have not addressed
compliance issues to date,
please make this your
1st Year 2000 resolution. The
consequences of not acting
promptly are too great to
ignore.
SummiT
Healthcare Management Resources
2630 West Freeway, Suite 126
Fort Worth, Texas 76102
the patient in the pre-op
area. Alternatively, you can
use the footnote (i.e. put a
small “1” at 0700 with a
corresponding “1” in the
comments section where
you write “Versed given
0700-0710 in pre-op.” You
may also have some better
way to document this, just
ensure that the pre-op
meds are somehow docu-
mented on the
timeline/bar graph.
Similarly when PACU time
is involved, char t the PACU
in and PACU out time on
the timeline/bar graph. For
example, if the case is
over at 0800, and you
entered PACU at 0810, the
timeline/bar graph should
note an “X” or tick mark at
0805 and a separate “X”
or tick mark at 0810, with
the first “X” or tick mark
noted as “PACU in,” and
the second noted as
“PACU out.” This process
may be duplicative, but
based on what the
Connecticut Medicaid audi-
tor used as the standard,
we would be remiss if we
did not advise you to pro-
tect against such overzeal-
ous auditors.
This article has been published with the permission of Vaughn & Joaquin Attorneys
At Law, 8810 Bluebonnet Blvd, Suite B, Baton Rouge, LA 225-769-1313
Summit Healthcare Management Resources, Inc.
1 - 8 8 8 - 8 5 4 - 3 8 2 2 • w w w. s u m m i t h m r. c o m
This newsletter is not intended to render professional services.The publisher assumes no liability for the reader’s use of the information herein.
All time, no matter how it is
spent, should be charted on
the time line/bar graph. An
auditor should be able to look
at “anesthesia start” time in
the box on your anesthesia
record and see a correlating
and corroborative tick mark
on the time line/bar graph.
Similarly, an auditor should be
able to look at your stated
“anesthesia end” time written
in the box on your anesthesia
record and see a correlating
and corroborative time char t-
ed on the time line/bar graph.
If the start and stop times are
charted on the time line as
well as written in the boxes
on the anesthesia record ,
auditors will have difficulty in
disallowing your time.
Do keep in mind that time
does not begin when you
talk to the patient in the
pre-op areas about the pre-
op exam conducted the day
before and/or verifying the
exam findings. The general
rule is that the pre-op exam
and eval, together with the
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anesthesia plan are already
bundled into the base units. Remember: The definition of time
The exception to this rule as defined in the Medicare
applies if you go over the Carrier’s Manual is: “Anesthesia
pre-op with the patient at time involves the continuous
actual presence of the anesthesi-
the same time you are
ologist (or of the medically-direct-
administering Versed or
ed CRNA, AA, resident or student
another form of anesthesia.
nurse anesthetist) and starts
You can count this time when the physician or anesthetist
because you are also begin- begins to prepare the patient for
ning to prepare the patient anesthesia care in the operating
for the administration of room or equivalent area and ends
anesthesia. Simply stated: when the anesthesiologist is no
You cannot bill for pre-op longer in personal attendance,
talk unless you are concur- that is, when the patient may be
rently administering pre-op safely placed under post-operative
meds which means you are supervision.”
actually billing for the
pre-op med time, not the Source: Medicare Carrier’s Manual,
“talk” time. Section 15018 G
If you are stumped by a billing, coding
or practice management question or
just need a “second” opinion, contact
our 48-Hour Anesthesia and Pain
Management Hotline. We will
access our network of industry
experts and guarantee to have a
response to your question within
48-hours.
Just contact Sandi Ross, Director of Practice
Development @ 1-888-854-3822, Ext. 219;
Fax: (817) 334-0235 or email: sross@summithmr.com