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									Coding and Compliance

          Credentialing and Recredentialing
            Program for Anesthesia Faculty

                      School of Medicine Compliance Office
Course Objectives

  Why coding and compliance is important to you
     and your practice

  Documenting anesthesiology services

  Teaching physician (TP) rules. In order to bill
     Medicare and Medicaid for services when working
     with residents and fellows, teaching
     anesthesiologists must abide by pertinent federal
     and state laws and regulations
Why coding and compliance
is important to you and your

   Providing good care while billing accurately and
   confidently requires:

    Doing only what is medically necessary

    Documenting what you do

    Billing what you document

Understanding and applying coding and compliance conventions can
improve the level of reimbursement for UNC P&A practices as well as
the quality of the medical record documentation.
Why Compliance

 Residents are paid through the hospital by Part A Medicare.
  Medicare pays a portion of the residents’ salaries based on the
  proportionate share of Medicare at the teaching hospital.

 Teaching physicians are paid by Part B Medicare on a fee-for-
  service basis.

 The government, through Medicare, will pay for both resident
  and TP services if both participate. If the TP does not participate
  in a given patient service, the TP cannot bill.
Why Compliance

 Medicare and Medicaid require teaching physician presence for
  key parts of anesthesia services and personal documentation of
  that presence in order to bill for the service

 Medicare requires similar personal presence and documentation
  for billing of evaluation and management services
  (consultations) and other procedures

 Medicaid consultations and other evaluation and management
  (E&M) services require that the TP be "immediately available" to
  the resident and use "direct supervision" for procedures. The
  teaching physician must co-sign the resident note and assume
  responsibility for the patient’s care.
Documenting Anesthesiology Services

This short course will focus on the services below which
account for over half of the dollar volume of all anesthesia

    General anesthesia services
    Consultations
    Daily inpatient follow-up
    Regional Anesthesia Procedure Note
    Subsequent Daily Management of Catheters
General Anesthesia Services
 General Anesthesia-medical direction

Medicare and Medicaid physician requirements for coverage
of medical direction of nurse anesthetists

   Perform a pre-anesthetic examination and evaluation
   Prescribe the anesthesia plan
   Participate personally in the most demanding procedures in
    the plan including induction and emergence
   Ensure that the anesthetist performs the anesthesia plan
   Monitor the course of the administration at intervals
   Remain in the operating suite for the entirety and available
    to return if needed
   Provide indicated post-anesthesia care
 Medical direction - documentation

Medicare and Medicaid require the billing physician to
document the following:

  Performance of pre-anesthesia exam and evaluation

  Provision of indicated post-anesthesia care

  Presence during some portion of the anesthesia

  Presence during the most demanding procedures
    including induction and emergence
Medicare/Medicaid require a concurrency modifier

-AA   - Physician personally performed.

-QY   - Medical direction of one CRNA by an anesthesiologist.

-QK -    Medical direction of two, three, or four concurrent
           anesthesia procedures involving qualified individuals.

-AD   - Medically supervised by a physician for more than
          four concurrent procedures.

-QX   - CRNA with medical direction by a physician.

-QZ   - CRNA without medical direction by a physician.

-QS   - Monitored anesthesiology care services (can be billed
          by a CRNA or a physician).
  Medical direction or supervision

 Medical direction of one CRNA
     payment at 50% of each provider’s allowable
 Medical direction of two, three or four concurrent procedures
    Physician services are not payable by Medicare or Medicaid if the billing
         leaves the immediate area of the operating suite for more than a short
           devotes extensive time to an emergency case or
           is otherwise not available to respond to the immediate needs of the patient

 Supervision of more than four concurrent procedures
     Anesthesiologists are reimbursed at a lower rate
     CRNA will get paid at the above rate
Teaching physicians and residents

Medicare and Medicaid payment may be made for
attending physician services when a resident is involved in
the patients care if the teaching physician:
    personally examines the patient
    is present at induction and emergence
    performs other activities that distinguish an attending
       physician relationship

The teaching physician must personally document h/her
involvement in the record.
How anesthesia services are paid

     Basic value
     Time units
     Physical status modifier
     Any qualifying circumstances
     Any additional modifiers for unusual
      procedures or services
 How anesthesia services are paid

 A basic value is listed for anesthetic management of
  most surgical procedures
    Base unit includes
       pre and post anesthesia care
       administration of fluids and/or blood products incident to
        anesthesia care
       interpretation of non-invasive monitoring
    Base unit does not include
       placement of arterial, central venous and pulmonary artery
       use of transesophageal echocardiography (TEE)
How anesthesia services are paid

 Time units
    Begins when the anesthesiologist begins to prepare the

    Ends when the patient may be safely placed in post-
     anesthesia supervision

    Generally reported in units of 15 minutes, Medicare
     requires actual minutes
 How anesthesia services are paid

 Physical status modifiers
All anesthesia services are reported using one of the following modifiers
                                                          Unit values
  P1 - A normal healthy patient                                 0
  P2 - A patient with mild systemic disease                    0
  P3 - A patient with severe systemic disease                  1
  P4 - A patient with severe systemic disease that
       is a constant threat to life                            2
  P5 - A moribund patient who is not expected to
       survive without the operation                           3
  P6 - A declared brain-dead patient whose organs
       are being removed for donor purposes                    0
 How anesthesia services are paid

  Qualifying circumstances
  Bill as many as apply for extraordinary conditions, unusual risk
  factors or notable conditions in addition to the procedure code

                                                            Unit values
    +99100 - Anesthesia for patient of extreme age,
            under one year and over 70                            1
    +99116 - Anesthesia complicated by utilization of
            total body hypothermia                                5
    +99135 - Anesthesia complicated by utilization of
            controlled hypotension                                5
    +99140 - Anesthesia complicated by emergency
            conditions (specify)                                  2

(an emergency is defined as existing when delay in treatment of the patient would
lead to a significant increase in the threat to life or body part.)
How anesthesia services are paid

  Additional modifiers for unusual procedures or

     22 Unusual Procedural Services: When the service(s) provided
       is greater than that usually required for the listed
       procedures, it may be identified by adding modifier “22” to
       the usual procedure code. Documentation is required to be
       sent with claim.

     23 Unusual Anesthesia: Occasionally a procedure which
       usually requires either no anesthesia or local anesthesia,
       because of unusual circumstances, must be done under
       general anesthesia.

     25 Significant, separately identifiable evaluation and
       management service performed by the same physician on
       the same day as a procedure. Added to the E&M service for
       both to be paid.
The Anesthesia Record

 The following two slides are instructions on
 completing the front and back side of the
 Anesthesia Record which is also used to extract
 billing information. It is the bread and butter of the
 practice, so it is important to know how to properly
 complete it and direct others to complete it to
 assure appropriate reimbursement.
  1.     Patient name and MR#                                                           1 Patient name and
  2.     Anesthesiology attending name                                                  medical record number
  3.     Resident/CRNA name
  4.     Date of service                            Write in any anesthesia-specific
                                                    diagnoses (for MAC, PA catheters,
  5.     OR room or location                        CVPs and A-lines) here.
  6.     Anesthesia start time                                                                          2
  7.     OR arrival time                                 10
  8.     OR leave time
  9.     Anesthesia stop time (signed over
         to PACU)
  10. Agent and/or drugs given incl
         amount and prox time)
  11. BP and heart rate monitoring                           6
                                                     5        7
  12. Reading for ECG, temp, pulse, O2
  13. Antibiotic, dose
For Medicare, teaching physician attestation of              9
presence must be completed
Document any procedures (PA Catheter,
epidural, TEE, A-line, CVP) with a procedure
note on the front of the record. Include medical
necessity.                                                   12
Record beginning and ending time for CPB

If placing an epidural or a catheter (brachial,
sciatic, femoral nerve) or performing a nerve
block, the note must state that it is for post-op
pain (may abbreviate “POP”)
The back side of the Anesthesia Record blue striped copy - for reimbursement
 1.   CPT code from ASA Relative Value Guide       2. Procedures (check box)
 3. When a procedure is performed by a different provider than will sign the bottom of
    the form, fill out “Placed” and “Managed” fields signed with complete name of
    resident or CRNA
 4. Intubation type and post-conceptual age sections for ABA reporting
5. Check mark          1.
  for each
  a. type                               4.
  anesthesia,          2.   3. 3.
  b. ABA
  c. location,
                 5a.         5b.             5c.
6. Fill in
  procedure,                                                                   6a.
  surgeon,                                                                           6b.
  resident/CR                                                                  6c.
  NA and
  signature                                                    6d.
Teaching physician documentation

 Print and sign name on the original (orange striped)
  Anesthesia Record form near the top right hand side
  after: “Anesthesia attending __________”

 Write a statement attesting to presence (if applicable)
  during induction, line placement, emergence and
  availability throughout and sign

 Services are not billed to Medicare or Medicaid
  until the teaching physician personally provides
  a statement of involvement
Evaluation and Management (E&M) Services
Consultations and daily inpatient care
Evaluation and Management Categories

There are dozens of different Evaluation and
Management (E&M) categories; only those shown
below are addressed in this course:

Inpatient E&M categories for

   Inpatient consultations (5 levels) 99251- 99255
   Subsequent hospital care (3 levels) 99231-99233

 A consultation is an E&M service provided by a physician
  whose opinion and advice is requested by another
  physician or appropriate source involved in that patient’s

 Consultations should be viewed as a three-part cycle (1) a
  request is made (2) an evaluation is undertaken and (3)
  an opinion is rendered and sent to the requesting

 The consultant may initiate diagnostic and/or therapeutic
  services at the same visit.
Medicare Outpatient E&M Allowables

                   Outpatient Visit Category
CPT Code
  Level    Established      New            Consultation

   1             $20.36           $32.93           $47.90

   2             $36.71           $62.26           $87.77

   3             $50.31           $92.58          $117.06

   4             $79.01        $131.29            $165.46

   5            $115.29        $166.63            $214.28
E&M Components

E&M services have three basic components identified

           History

           Physical examination

           Medical decision making
E&M Components (continued)

Consultations (inpatient and outpatient) must include
all three of the components shown below.

Subsequent hospital care must include any two of the

         History
         Physical examination
         Medical decision making
E&M Levels - Subcomponents

In and out-patient consults all have 5 levels of
service; subsequent hospital care has 3 levels.

The level is determined by evaluating the three basic
components of E&M services with attention to the
subcomponents, shown on the next three slides.
 E&M Levels – History Subcomponents

The three basic components of E&M services: history,
physical examination and medical decision making have the
subcomponents shown below and on the next two slides.


           History of present illness
           Review of systems
           Past family and social history
E&M Levels – Physical Examination Subcomponent

Physical examination - based on the examination of
organ systems/body areas as defined by:

         the 1995 Medicare guidelines
         the 1997 Medicare guidelines

The treating physician determines which of the above to
E&M Levels – Medical Decision Making Subcomponent

Medical decision making takes into account any two of
the following three subcomponents

     Number of diagnostic or management options

     Amount and complexity of data reviewed

     Overall risk of the treatment plan or patient’s
E&M Levels, Other billing information

  Though not required, there is a detailed E&M coding
   course at

  The laminated, lab coat pocket-sized physician’s coding
   cards are valuable guides to correct coding and

  Additional training on anesthesiology billing from Per-Se
   Technologies is available on the Department’s network.
   It can be found on anesdata/shared/compliance and
   documentation training/physician anesthesia coding

 The attending physician must personally perform or
  observe the key portions of the history, physical
  exam and medical decision making and write a
  personal note so indicating in the record for Medicare

 Inpatient anesthesia service consults should be
  documented on the WebCIS “create note” template
  for Inpatient Consultation Notes. When entered by a
  resident they are forwarded to the attending
  anesthesiologist’s activity list for the appropriate
  personal attestation and signature.
1.   Pain site
2.   Requested by
3.   Patient location
4.   Indication                                                      2a.          2b.
5.   Time interval for block placement              3.
     and date
6.   Resident/CRNA/Attending signature
     and provider number
7.   Only if block is for post-op pain, mark               5.
     procedure and Dx on back of form

        7a.                7b.

                                                     6a.                         6a.

 Complete “Subsequent
   Daily Management of
   Catheter” form each day
   the patient is seen for an
   epidural placed solely for
   post-op pain
 Write the reason you are
   seeing the patient in the
   diagnosis blank
 For Medicare to be billed,
   the attending must be
   present for the key
   portions of the service
   and document h/her           I was present for the evaluation and agree
                                with the assessment.
   involvement in the note.                  Attending signature/date required
   A preprinted statement
   does not suffice.                “Post-op pain” is not sufficient
Where To Get Help


  School of Medicine Compliance Office 843-8638
     Charles Foskey, Compliance Officer
     Chris Carreiro, CPC, Compliance Review Analyst
     Heather Scott, CPC, Assoc. Compliance Officer
     Nirmal Gulati, MS, CPC, Compliance Auditor
     Lateefah Ruff, Office Assistant

  Confidential Help Line for compliance concerns

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