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Physician Compliance New Provider and Reappointment Training for Anesthesiology Coding Review basic principles of compliance and documentation of anesthesia services Review documentation and medical direction requirements when performing services with Residents Fellows and Certified Registere ID: 908809

physician anesthesia patient services anesthesia physician services patient procedures medicare medical concurrent guidance medically time documentation cases present direction




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UNC HealthDepartment of Physician Compliance

New Provider and Reappointment Training for Anesthesiology Coding


Review basic principles of compliance and documentation of anesthesia services

Review documentation and medical direction requirements when performing services with Residents, Fellows, and Certified Registered Nurse

Anesthetists (CRNA)

Course Objectives



3Appropriate billing requires three components:

Doing only what is medically necessary

Documenting what is done

Billing what is documented

Understanding and applying coding and documentation conventions allows for compliant billing, potential for increased revenue, and generally improved quality of the medical record documentation.

Principles of Coding and Documentation


Appropriate documentation and billing practices make for good patient care and maximized compensation.Federal Oversight:

Recovery Audit Contractors (

RACs) — Medicare, Medicaid, and commercial insurers pay third party contractors to recoup inappropriately documented or billed services

Office of Inspector General (OIG),

Health & Human

Services — works

with the Department of Justice to investigate suspected abuse or fraudulent claims

Routine error rate testing and auditing

programsCivil monetary penalties under the False Claims Act are treble damages, plus $10,781.40 to $21,562.80 per claim (per Bipartisan Budget Act of 2015; subject to annual inflation adjustment)

Compliance is Essential to Proper Reimbursement



Coding and Documenting Anesthesia Services5


The building blocks of reimbursement are the unit values represented by:Reimbursement of Anesthesia Services



7A basic unit is a numerical value to reflect the complexity of physician work associated with a surgical procedure (range 3 to 30 units)


base unit includes:





administration of fluids and/or blood products incident to anesthesia care

interpretation of non-invasive monitoring

The base unit does not include:placement of arterial, central venous, and pulmonary artery catheters

use of


echocardiography (TEE


Post-op pain blocks; peripheral nerve blocks; epidural catheters.

Basic Value


8Anesthesia time is defined as the period during which an anesthesia practitioner is present with the patient.


starts when the anesthesia practitioner begins to prepare the patient in the holding area or equivalent area for anesthesia services and ends when the anesthesia practitioner is no longer furnishing anesthesia services to the patient; that is, when the patient has been transferred to a non-anesthesia care provider, typically occurring at UNC Hospital in the PACU or ICU.

Anesthesia time is a continuous time period from the


of the start of anesthesia to the


of the end of an anesthesia service.

1 unit = 15 minutes


Measuring Time


9All anesthesia services are reported using one of the following modifiers:


- A normal healthy patient

P2 - A patient with mild systemic disease


- A patient with severe systemic disease


- A patient with severe systemic disease that is a constant threat to life

P5 - A moribund patient who is not expected to survive without the operationP6

- A declared brain-dead patient whose organs are being removed for donor purposes Example: 00100-P1 – Anesthesia for procedures on salivary glands, including biopsy – normal healthy



These modifiers are not recognized by government payors, but may be reimbursed by other commercial payors.

Physical Status Modifiers


10In addition to the procedure code, extraordinary conditions, unusual risk factors, or notable conditions may be billed, if applicable. More than one qualifying circumstance may be selected.


Anesthesia for patient of extreme age, younger than 1 year and older than 70


Anesthesia complicated by utilization of total body hypothermia


Anesthesia complicated by utilization of controlled hypotension


Anesthesia complicated by emergency conditions (specify)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.

As with the physical status modifiers, these codes are also not recognized by government payors, but may be reimbursed by other commercial payors.

Qualifying Circumstances


11Medical and Surgical Procedures Included in Bundled Services

General anesthesia, regional anesthesia, and MAC services are considered a total or global package of services, and include the following:

The usual preoperative and postoperative visits;

Anesthesia services during the procedure;

Administration of intravenous fluids including blood or blood products;

Intra-operative laboratory evaluations;

The usual monitoring services [

such as electrocardiogram (ECG), temperature, blood pressure, pulse oximetry,


, infrared end-tidal gas analysis, mass spectrography, bispectral electroencephalography, and transcranial Doppler

] and their interpretation.

Anesthesia Bundled Services


12Medical and Surgical Procedures Not Included as Bundled Services

The following forms of monitoring are not included in the total or global package and may be billed separately:

Pulmonary artery catheter insertion;

Central venous catheter insertion;

Intra-arterial catheter insertion;

Nerve blocks for postoperative pain relief (single injections and continuous catheters, including epidural, spinal, and peripheral nerve blockade);

Ultrasound-guided central venous access and assisted peripheral nerve blockade;


echocardiography (TEE) monitoring and interpretation.

Anesthesia Services that are separately billable


Medicare Teaching Physician Guidelines13


Medicare pays for Resident Physician services through Part A. Medicare Part B will pay for Teaching Physician (


services with the Resident Physician when the TP participates and documents his/her involvement in the service. If the TP does not participate in a given patient service when a Resident is involved and meet

specific documentation requirements, the TP may not bill for the service.

Why the stringent Medicare requirements? Medicare does not want to pay twice!



The Teaching Anesthesiologist must document in the medical record that he/she was present during all critical (or key) portions of the procedure.

The Teaching Anesthesiologist’s physical presence during only the preoperative or postoperative visit with the patient is not sufficient.

When the Teaching Anesthesiologist is involved in two concurrent anesthesia cases with Residents, he/she may bill the usual base units and anesthesia time for the amount of time he/she is present with the Resident.

The Teaching Anesthesiologist must be present and document that they were present for the key/critical portions of the anesthesia service or procedure.

Must be immediately available to furnish anesthesia services during the entire procedure or have another teaching anesthesiologist within same group that can be immediately available to the Resident.




Medicare Teaching Physician Requirements for Personally Performed Time



The A/B MAC determines payment at the medically directed rate for the physician on the basis of


of the allowance for the service performed by the physician alone. Payment will be made at the medically directed rate if the physician medically directs qualified individuals (all of whom could be CRNAs, anesthesiologists' assistants, interns, residents, or combinations of these individuals) 

in two, three, or four concurrent cases and the physician or other provider qualified to administer anesthesia performs the following activities.

Performs a pre-anesthetic examination and evaluation;

Prescribes the anesthesia plan;

Personally participates in the most demanding procedures in the anesthesia plan, including

, if applicable,

 induction and emergence;

Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified individual


Monitors the course of anesthesia administration at frequent intervals;

Remains physically present and available for immediate diagnosis and treatment of emergencies; and

Provides indicated post-anesthesia



§482.12 (c)(1)(i) generally provides broad authority to physicians to delegate tasks to other qualified medical personnel, the more stringent requirements at §482.52(b)(1) do not permit delegation of the pre-anesthesia evaluation to practitioners who are not qualified to administer anesthesia




Medical Direction of Anesthesia Services




The requirements for payment at the medically directed rate also apply to cases involving student nurse anesthetists if the physician medically directs two concurrent cases, with each of the two cases involving a student nurse anesthetist, or the physician directs one case involving a student nurse anesthetist and another involving a qualified individual (for example: CRNA, anesthesiologist's assistant, intern or resident).

The requirements for payment at the medically directed rate do not apply to a single resident case that is concurrent to another anesthesia case paid at the medically directed rate or to two concurrent anesthesia cases involving residents.

Medicare Payment at the Medically Directed Rate


18Medical direction of two,


or four concurrent procedures

Physician services are not payable by Medicare or Medicaid if the billing physician:

leaves the immediate area of the operating suite for more than a short duration;

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


Reimbursed at a supervision rather than medical direction rate

Requires pre-anesthesia exam and determination of the anesthetic agent

If the billing physician is present at induction, reimbursement


Medical Direction – Concurrent Procedures



The physician must document in the medical record that

they performed the pre-anesthetic examination and evaluation. Physicians must also document that:

they provided indicated post-anesthesia care,

were present during some portion of the anesthesia monitoring, and

were present during the most demanding procedures 

in the anesthesia plan, 

including induction and emergence, where indicated.

If anesthesiologists are in a group practice, one physician member may provide the pre- anesthesia examination and evaluation while another fulfills the other criteria. Similarly, one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service. However, the medical record must indicate that the services were furnished by physicians and identify the physicians who furnished them



Direction — Documentation



20Medical direction of two, three, or four concurrent procedures

Physician services are not payable by Medicare or Medicaid if the billing physician:

leaves the immediate area of the operating suite for more than a short duration;

devotes extensive time to an emergency case; or

is otherwise not available to respond to the immediate needs of the patient.

If a physician is overseeing more than four cases, the payment rate changes from medical direction to medical supervision.

NOTE: Concurrency


refers to the maximum number of procedures that the physician is medically directing within the context of a single procedure and whether these other procedures overlap each other. Concurrency is not dependent on each of the cases involving a Medicare patient. For example, if an anesthesiologist 

medically directs three concurrent procedures, two of which involve non-Medicare patients and the remaining a Medicare patient, this represents three concurrent cases.



Medical Direction

of Concurrent




Contact us – We are here to help!


Robin Davis Shuping, RN, MHA, CPC

| Executive Director, Physician




Phone 984.974.1017



Noel Wagner, RN, MSN,



Associate Director, Physician


UNC Health

Phone 984.974.1308


Confidential Hotline:






Thank you!