Ho-Hum and Humdrum
Before we explore the anomalous, let’s review the usual. The normal, standard anesthesia service involves billing time—typically running in unbroken fashion—from a designated start time to a designated stop time. With most cases and with most groups, the default start time is going to be the moment the anesthesia provider walks into the operating room (OR) with the patient.
One of the reasons why this circumstance can trigger the beginning of anesthesia time is because it has been historically accepted by both the specialty and the payer community as a perfectly appropriate point at which to start to the case. Another reason you can begin your time at the first moment you and the patient are together in the OR is due to the language of the Centers for Medicare & Medicaid Services (CMS) and the Code of Federal Regulation (CFRs) on this subject. For example, the Medicare Claims Processing Manual (MCPM), in speaking about anesthesia start time, puts it this way:
It starts when the anesthesia practitioner begins to prepare the patient for anesthesia services in the operating room or an equivalent area . . . .
So, the start of anesthesia time is directly tied to being in the OR with the patient; and, presumably, once you are in the OR, you are, in fact, “beginning to prepare the patient for anesthesia services.”
Okay, so, pretty much everyone agrees that, in a normal case, under normal circumstances, you can list your start time concurrent with your “in OR” or “in room” time. Now, what about normal stop time? Let’s quickly review that, as well.
Typically, your anesthesia stop time should be concurrent with the time you turn the patient over to other appropriate personnel—generally, the PACU nurse or ICU staff. We know this because the MCPM states the following about stop time:
. . . and ends when the anesthesia practitioner is no longer furnishing anesthesia services to the patient, that is, when the patient may be placed safely under postoperative care.
So, your care transfer time is concurrent with your anesthesia stop time. They are one and the same. Usually, you’re in the PACU with the patients for a few minutes. You turn the patient over to the nurse, you denote the time and you list that time on the anesthesia record as your stop time. Seems simple enough.
But, then there are those cases where things are not so normal.
Where Strangeness Abounds
There may be times when you actually “begin to prepare the patient for anesthesia services” in a location other than the OR. Let’s say you’re placing a regional block—that is to be used as the main anesthetic for the case—prior to entering the OR. You place that block in the preop holding area (PHA). We (and multiple compliance attorneys) have historically agreed that the PHA acts as an “equivalent area” to the OR, in keeping with the start time verbiage cited above in the MCPM.
But what about delays? If there is an unusual pause on the front end of the case, due to the tardiness of the surgeon or equipment failure, etc., we recommend that you still start your time with the moment you entered the OR with the patient. We further recommend that you document on the record the reason for a larger than normal time gap between anesthesia start time and surgery start time. It will be up to the payer to determine whether or not any time needs to be deducted.
There are also, occasionally, delays on the back end. Perhaps the PACU is not yet available, so your transfer of the patient to other appropriate staff must be postponed. How do you handle the billing in this situation? As always, we must look to the authoritative sources; and, here, we find that both the MCPM and the CFRs define anesthesia stop time as follows:
. . . and ends when the anesthesia practitioner is no longer furnishing anesthesia services to the patient, that is, when the patient may be placed safely under postoperative care.
Furthermore, the historic position of both the American Medical Association (AMA) and the ASA has mirrored the above verbiage. This language does not specify where the care transfer occurs; only that when it occurs, that’s your anesthesia stop time. So, you are expressly allowed to bill time until that transfer of the patient. If the transfer is delayed—for whatever reason—the anesthesia team is still responsible for that patient’s care and that time is billable.
Having said that, we recommend that, where the delay is caused by the PACU not being available and such delay involved more than a unit of time (15 minutes) beyond the surgery end time, you should document on the anesthesia record the reason for the inordinate amount of post-surgical time being claimed.
Yes, sometimes, things can get a little weird, but following the authoritative guidance in such situations can provide certain protections in the event of an auditor’s pushback.