Health Information Management

Insufficient documentation and anatomy-based coding distinctions challenge anesthesia coders

JustCoding News: Inpatient, February 17, 2010

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by Lois E. Mazza, CPC, PCA

The fact that providers use various methods to code for anesthesia makes anesthesia coding unique. Surgical codes determine the appropriate anesthesia codes to report. So coders must first ascertain the surgical codes by obtaining them from a super bill, for example, or by using a spreadsheet that lists the codes for surgeries that require anesthesia services. Many anesthesia coders are also surgical coders—they first review the surgical note to obtain the surgery codes and then refer to these codes to assign the appropriate anesthesia codes.

These factors contribute to the unique challenges anesthesia coders face. Consider three of the most common problems related to anesthesia coding.

Missing information on the charge sheet. The amount of time the physician spent providing services as well as the base value units for the assigned anesthesia code determines payment for anesthesia services.

The base value units assigned to anesthesia codes depend on the complexity of the services. For example, anesthesia code 00400 (Anesthesia for procedures on the integumentary system [skin] on the extremities, anterior trunk and perineum; not otherwise specified) is worth three base value units. Anesthesia code 00563 (Anesthesia for procedures on heart, pericardial sac, and great vessels of chest; with pump oxygenator with hypothermic circulatory arrest) is worth 25 units. The complexity of the case makes the significant difference.

When start and stop times are missing from the charge sheet, the coder must seek out this information. This data should be readily available on the anesthesia record. Many facilities employ electronic medical records to which coders should have access. Ideally, obtaining this information will be just a matter of checking the record for the correct times, which you can also often verify by consulting nursing and surgical notes.

Other information on the charge sheet that could be problematic if it is missing includes:

  • The name of the attending anesthesiologist(s)
  • The name of any resident(s) who may have provided services
  • The ratio of residents to attending physician (in medical direction cases)
  • Diagnosis for nonsurgical procedures such as intubations and epidurals that physicians place for pain relief
  • Date of service

Missing information in the record. Anesthesia records include a timeline of events, including the time the physician administers the anesthesia, the time the patient emerges from anesthesia, as well as a notation of times for all critical portions of the anesthesia service.

Sometimes, documentation does not portray a complete picture of this timeline. In addition to having an incomplete timeline, there are other details that are sometimes missing from the medical record. These can include:

  • An attending physician statement in cases involving medical direction, attesting that he/she was present and immediately available for the entire procedure and participated in all key portions (e.g., induction, extubation)
  • The start and/or stop times
  • An attending physician’s signature on the anesthesia record and/or the orders 
  • The date of service
  • The name of the surgeon
  • The name of the procedure(s)

Code assignment hinges on anatomy. Anesthesia code selection sometimes depends on the anatomy the procedure addresses. For example, consider the following clinical scenarios:

Anterior lumbar interbody fusion is a spinal surgery in which a physician fuses injured or diseased vertebrae in the lumbar region of the spine. ‘Anterior’ indicates the approach for this procedure, more specifically that the physician performs the incision with the patient supine. The surgical incision is from the front.

Educate your surgeons about the importance of clearly documenting the approach, the section of the spine having the fusion, and any instrumentation involved in the fusion. A service that includes spinal fusion located in the lumbar region is worth eight base units but 10 base units when the fusion is located in the cervical region. When the procedure involves spinal instrumentation, which might include the placement of a cage, screws, or plate, the anesthesia code is worth 13 base units.

Location is often critical in determining the correct anesthesia codes for procedures involving the abdominal cavity. The base unit value might go up or down depending on the location, the approach, and the type of procedure the physician performs in the abdominal cavity.

When selecting anesthesia codes for cardiac bypass surgery, consider whether the surgery was done on- or off-pump. During this type of surgery, physicians often use a pump to keep the patient’s heart beating during surgery. The pump does the work for the heart. When the physician performs the surgery off-pump, the case becomes more complex for the anesthesiologist and therefore has a higher base value.

Often during thoracotomy and thoracostomy procedures, physicians will employ one-lung ventilation, which involves deflating one lung during the procedure. This makes the case more complex for the anesthesiologist and adds five base units to the anesthesia reimbursement.

Deep hypothermic circulatory arrest is another technique physicians often employ during cardiac surgeries. During deep hypothermic circulatory arrest, the physician stops the patient’s circulation and cools the patient significantly to help reduce the ill effects of stopped circulation. This technique makes the case much more complex for the anesthesiologist and results in an extra five base value units.

When using this technique, the physician must document the lowest temperature the patient experienced during the technique as well as the duration of time the arrest lasted. Certain language in the surgeon’s note can help coders to identify when the physician has used deep hypothermic circulatory arrest. Look for the following verbiage:

  • The patient’s head was packed in ice
  • The cardiac field was flooded with sodium pentothal
  • The patient is placed in deep Trendelenburg position (i.e., flat on the back with the feet higher then the head)

Specific rules apply for medical direction
In some facilities, such as teaching hospitals, a qualified anesthesiologist will direct other individuals providing anesthesia care. Medicare has strict rules that apply for such circumstances.

CMS has identified the following seven steps the supervising anesthesiologist must follow to be eligible for reimbursement:
1. Perform a pre-anesthetic examination and evaluation
2. Form an anesthesia plan
3. Be present for all critical portions of the procedure, including induction, emergence (i.e., extubation or when the patient is being brought out of anesthesia), and any other demanding portion of the procedure
4. Ensure that a qualified individual performs any procedure in the anesthetic plan not personally performed by the supervising physician
5. Monitor the course of the administration of anesthesia at frequent intervals
6. Remain immediately available for any potential emergency situations
7. Provide post-anesthesia care and orders

Strategies to prevent problems
The best way to resolve problems is to head them off before they start, of course. Communication, education, and accountability are vital to that end.

Communication. Coders need to have open lines of communication with surgeons as well as anesthesiologists to address questions regarding documentation. Coders must have access to surgical or procedure notes so that they can verify details related to the techniques the physician uses and confirm information about the procedures.

Education. Many coding problems can be resolved through education that coders can provide to physicians. Physicians need to understand the effect insufficient documentation can have when coders are trying to determine anesthesia codes. Because physicians are notoriously busy, it’s a challenge just getting physicians to agree to meet, but it’s important to remain persistent and convey the importance of these meetings.

Accountability. Staff members will continue to repeat the same mistakes if nobody steps in to correct them. Plan frequent chart audits to help both physicians and coders alike understand how missing or incorrect information can affect reimbursement.

Editor’s note: Lois E. Mazza, CPC, PCA, is a certified professional coder at Lahey Clinic Medical Center in Burlington, MA. E-mail her at

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