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Anesthesia Documentation: Maximize Revenue with Proper Documentation

To maximize practice revenue and payment from payors, your billing company must submit clean claims. For general billing, this is a fairly simple practice but when it comes to anesthesia billing the complications increase tenfold.

Here are some reminders about common provider documentation omission so billing can ensure appropriate coding and payment.

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Anesthesia Coding Documentation Requirements

Every component of anesthesiology has a specific code number assigned to it from individual procedures to body parts to types of anesthetic administration. It is critical that you remember to document specific details of your patient interactions so claims can be coded to maximize payment.

Complete documentation helps coders be more precise when translating notes to claims.

Shoulder and Knee Arthroscopy – Diagnostic v. Surgical

Anesthesia base units vary for diagnostic and surgical arthroscopies in the shoulder and knee. When noting these procedures in the anesthesia record, don’t minimize the service to “knee scope” or “shoulder scope”. Make sure to include in the procedure description on your anesthesia record whether the procedure was diagnostic or surgical.

Instrumentation in Spinal Fusion Procedures

Be sure to include whether or not instrumentation was used for spinal fusion procedures. The use of instrumentation increases anesthesia base units to 13 (from 8 or 10). If instrumentation is used, make sure to include terms such as “instrumentation”, “plates/screws” or “biomechanical cage” in the procedure description on the anesthesia record.

Multi-Level Spinal Procedures

When performing anesthesia for any spinal surgery (e.g. laminectomy, discectomy, fusion), include notes on which spinal levels were involved (i.e., C4-C6, or L3-L5). Any time a surgical procedure involves more than two vertebral segments/vertebra, anesthesia base units increase to 13 base units (from 8 or 10).

Cardioverter-Defibrillator Insertion

Anesthesia for AICD testing carries a higher base unit (10) than transvenous insertion/removal of AICD leads and/or generator placement (7 units) for several commercial insurers. Be sure to include the term “with testing” for AICD placement in the procedure field in the anesthesia record, when performed.

Blocks for Post-Op Pain Management

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When performing neuraxial or peripheral nerve blocks for postoperative pain management, be sure your documentation states that the block was placed (1) exclusively for postop pain control, and (2) at the request of the surgeon.  Many payers withhold payment for these services if the anesthesia provider’s records don’t show both conditions were met.

Ultrasound Guidance for Line/Block Placement

Ultrasound Guidance is a billable service when utilized for central venous access procedures and for needle placement when performing many peripheral nerve blocks for post-op pain management. Providers must make note of ultrasound guidance in their procedure notes and are required to retain an image copy in the patient record for this charge to be billable. Many payers require providers to submit a copy of the localization image prior to making payment for this service.

Procedural Services with Medically Directed or CRNA-Only Cases

If invasive monitoring lines or postoperative pain services are performed in conjunction with medically directed anesthesia cases, it is critical that the medical record specifies which provider performed which procedural services. Many payers will not make payment for certain procedural services performed by non-physician providers (e.g. post-op pain blocks) and it is imperative that these services are billed under the physician whenever appropriate.

Maximize Revenue Beyond Coded Claims

Of course, there’s more to maximizing revenue than just submitting clean claims.

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You need an anesthesia billing company that is dedicated to submitting and resubmitting claims again and again until you are paid in full. The unfortunate reality is that payors often underpay compared to their contracted amounts – even when the claim is perfect. Payors have specific contracts with every doctor, so keeping track of the agreed-upon amounts for every procedure and across every doctor is a daunting task.

To get everything you are owed, you need a billing partner that can track your contracts with each payor and compare every single line item when payments come in. If payments don’t match agreed-upon rates, then the claim should be resubmitted until it is paid in full.

Resubmitting claims for contracted payment amounts can increase your take-home 5-15%.

Looking for a Billing Partner?

Fusion Anesthesia provides comprehensive billing, consulting, and practice management services exclusively for anesthesia professionals. In addition to having a relentless reconciliation process like the one described above, we can help you improve practice operations and negotiate beneficial contracts for your group with the hospital. By taking this comprehensive approach to billing and practice management we help practices optimize operations and increase revenue by 5-15%.

Sound like something you’re looking for? Get in touch and we will be happy to review our processes and available services with you.

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