Strong documentation is the key to effective coding. Without accurate clinical notes, compliance risks increase and reimbursements are reduced. ReveNews recently spoke with McKesson certified coders about common documentation errors in anesthesiology.

Lisa Zigarovich, CPC, CANPC, coding manager, anesthesia division, McKesson Business Performance Services (McKesson), said thorough documentation in the anesthesia record is not only essential for maintaining compliance with payer regulations but will also greatly improve the efficiency of charge processing. She identified a number of frequent anesthesia documentation mistakes:

  1. Inability to determine ancillary service placement time (i.e., invasive lines and postoperative pain blocks). Medical record documentation should clearly support an invasive line and post-operative pain blocks placement time for the proper billing of anesthesia time. These ancillary procedures are “flat-fee” services that do not have a time component and are therefore paid separately. Invasive lines (i.e., arterial line, CVP and Swan-Ganz catheters) and blocks placed for postoperative pain management may not have placement times included in billable anesthesia time if placed prior to induction or after emergence. Those lines that are placed after induction but prior to emergence do not need to have placement time deducted.
  2. Postoperative pain blocks: Unclear documentation regarding the purpose of the block. Medically necessary postoperative pain management services that cannot be rendered by the surgeon may be provided by an anesthesia provider. However, clear documentation in the medical record that supports the primary purpose of postoperative pain management is critical to coding and billing the service. Also essential is the surgeon’s documented request for the service. When the anesthesia for the surgical procedure is not dependent on the efficacy of the block, and documentation supports the block’s purpose for post-operative pain management as well as the surgeon’s request, the block becomes a distinct procedural service that may be unbundled from the anesthesia service.
  3. Failure of supervising physician to complete medical direction attestations when supervising a CRNA/AA. The Centers for Medicare & Medicaid Services (CMS) makes it clear that when providing medically directed services, the physician must document in the medical record that he or she performed a pre-anesthetic examination and evaluation, documented that indicated postoperative care was provided, was present during some portion of the monitoring, and was present during the most demanding procedures, including induction and emergence, where indicated. Documentation is the responsibility of the physician and not a CRNA or AA. Checkboxes alone should be avoided when attempting to satisfy medical direction criteria, since ambiguity exists as to who is actually confirming or attesting to those events. 
  4. Premature completion of Surgical Procedure(s) section of the anesthesia record. Anesthesia providers should complete the surgical procedure(s) performed section of the anesthesia record immediately upon completion of surgery. Those who complete this section prior to surgery (based on the scheduled procedure) -- and fail to update it in instances where further expansion of the originally intended procedure is indicated -- run the risk of decreased revenueDocumentation of all procedures performed during the anesthesia encounter allows that the highest valued service is coded and billed. Incomplete and/or insufficient procedural descriptions in the anesthesia record delays charge processing, since the coder is required to seek additional supporting documentation.
  5. Insufficient teaching physician guideline. Anesthesiologists may be reimbursed at the personally performed rate for anesthesia services (i.e., the regular fee schedule level) when he or she is involved in the training of a resident in one or two concurrent cases involving residents, provided that the teaching physician guidelines are met. The teaching anesthesiologist or another anesthesiologist in the same group must be present during all critical or key portions of the anesthesia service and be immediately available. The teaching physician must therefore document that he or she was present during all critical (or key) portions of the procedure and that another teaching anesthesiologist was immediately available as necessary.

As important as accuracy is in today’s environment, Zigarovich said detailed and precise clinical notes will become even more essential once the ICD-10 codes sets take effect in October of this year. ICD-10 documentation requires considerably more clinical and anatomical specificity than the current ICD-9 system.

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About the author

Mary Jo Gross, CPC, CANPC of Compliance – Anesthesia and Pain Management, McKesson Business Performance Services