Risk and complication of anesthesia

Anesthesia - Risks and Complications

Although all types of anesthesia involve some risk, major side effects and complications from anesthesia are uncommon. Your specific risks depend on your health, the type of anesthesia used, and your response to anesthesia.

Personal risk factors

Your age may be a risk factor. In general, the risks associated with anesthesia and surgery increase in older people.

Certain medical conditions, such as heart, circulation, or nervous system problems, increase your risk of complications from anesthesia.

Some medicines can raise your risk of problems too. Make a list of all the prescription and over-the-counter medicines you take. And share your list with your doctors.

If you smoke, drink alcohol, or use illegal drugs, you may be more likely to have problems from anesthesia. It's important that you are honest when you talk with your surgeon and anesthesia specialist.

 

Anesthesia specialists, anesthesiologist and Anesthetist definition

Anesthesia specialists

Anesthesia specialists are responsible for making informed medical decisions to provide comfort and maintain vital life functions while you are receiving anesthesia and in recovery.

Anesthesia specialists include anesthesiologists and qualified nurse or dental anesthetists.

Anesthesiologist

Anesthesiologists are medical doctors who, after obtaining their medical degree and completing their internship, complete an additional 3 years of specialized training in an accredited anesthesiology residency program. They are certified by the American Board of Anesthesiology. As medical doctors, they have a wide range of knowledge about medications, medical care for diseases, how the human body works, and how it responds to the stress of surgery.

Anesthetist

Most anesthetists are nurses who have graduated from an accredited nurse anesthetist program and who have been certified by the American Association of Nurse Anesthetists to become a certified registered nurse anesthetist (CRNA). Nurse anesthetists are advanced practice nurses with specialized skills in anesthesia administration. A nurse anesthetist is usually supervised by an anesthesiologist or a surgeon, although law and practice may vary by state.

 

ANESTHESIOLOGIST DIRECTED ANESTHESIA

Medical direction may apply to a single anesthesia service furnished by a CRNA or up to four
concurrent anesthesia services. A physician who is directing the administration of anesthesia to four
surgical members is not expected to be involved routinely in furnishing any additional services to other
members. Addressing an emergency of short duration in the immediate area, administering an
epidural or caudal anesthetic to ease labor pain, or periodic rather than continual monitoring of an
obstetrical member would not substantially diminish the physician’s capacity to direct the CRNA
services.

The medical directing anesthesiologist must document in the member’s medical record that all
medical direction requirements have been met, including:

• Perform the pre-anesthetic examination and evaluation

• Prescribe the anesthesia plan


• Participate personally in the most demanding aspects of the anesthesia plan, including, if
applicable, induction and emergence

• Ensure a qualified individual performs any procedure in the anesthesia plan he/she does not
perform personally

• Monitor the course of anesthesia administration at frequent intervals

• Remain physically present and available for immediate diagnosis and treatment of emergency
that may develop

• Provide indicated post-anesthesia care.

A physician may appropriately receive members entering the operating suite for the next surgery while
directing concurrent anesthesia procedures. However, checking or discharging members in the
recovery room and handling scheduling matters are not compatible with reimbursement to the
physician for directing concurrent anesthesia procedures.

PCA - Patient Controlled Analgesia

Patient Controlled Analgesia

Patient controlled analgesia (PCA) services are reimbursable when they are
administered by an anesthesiologist and are performed for the control of postoperative
pain. A separately identifiable physician-recipient encounter should
be reflected in the medical record documentation. PCA pumps are usually
administered through an intravenous (IV) line or the PCA pump is connected
to an epidural catheter line.

Daily management of a PCA pump through an IV line is disallowed. When an
anesthesiologist provides the management of the PCA pump through an IV
line, the anesthesiologist will be allowed a total of four units and will be
considered a global payment for the management regardless of the number of
days the recipient remains on the pump. Use procedure code 90784 for daily
hospital management of intravenous patient-controlled analgesia.

The anesthesiologist should use the appropriate procedure code(s) when
filing claims for a single injection or for an injection including catheter
placement (epidural, subarachnoid, cervical, thoracic, lumbar, or sacral) when
the PCA pump is connected to an epidural line. Placement of the epidural
catheter and daily management of a subarachnoid or epidural catheter is not
reimbursable on the same date of service. Daily management of a
subarachnoid or epidural catheter is reimbursable on subsequent days.

Delivery of pain medication through intermittent injections, a regular infusion,
or by a PCA pump is included in the management of an epidural line whether
a registered nurse or a physician administers it. Additional units for a PCA
pump that is connected to an epidural line is not separately reimbursable.
The global surgical reimbursement fee to the surgeon includes the
management of a PCA pump for post-operative pain control and is not a
separately reimbursable item. Similarly, a physician’s global medical service
reimbursement includes the management of a PCA pump for recipients with
chronic pain control or terminal cancer and is not separately reimbursable.

Biling and coding tip for anesthesia CPT codes

CPT Anesthesia Code List

00100–00222 Head

00100 Anesthesia for procedures on salivary

glands, including biopsy

00102 Anesthesia for procedures on plastic

repair of cleft lip

Coding Tip

Do not use code 00102 for procedures performed on

the lip for conditions other than repair of cleft lip. For

other, non-cleft lip repairs, see code 00300.

For cleft palate repairs, see 00172.

00103 Anesthesia for reconstructive procedures

of eyelid (eg, blepharoplasty, ptosis

surgery)

00104 Anesthesia for electroconvulsive therapy

Coding Tip

Code 00104 may be denied when multiple electroconvulsive therapy (ECT) is provided. ECT (CPT code 90871) is a noncovered service by Medicare. Therefore, when anesthesia is performed for this reason, it will be denied as such.

00120 Anesthesia for procedures on external, middle, and inner ear including biopsy; not otherwise specified

00124 otoscopy

00126 tympanotomy

Coding Tip

Codes 00120–00126 each identify a unilateral service. If the surgeon performs bilateral surgical services, use modifier 50 (bilateral procedure).

00140 Anesthesia for procedures on eye; not otherwise specified

00142 lens surgery

00144 corneal transplant

Coding Tip

Codes 00140–00144 each identify a unilateral service. If the surgeon performs bilateral surgical services, use modifier 50 (bilateral procedure).

00145 Anesthesia for procedures on eye; vitreoretinal surgery

Coding Tip

Code 00145 is for a unilateral service. If the surgeon performs bilateral surgical services, use modifier 50 (bilateral procedure).

This code is appropriate to use on any vitreoretinal procedures requiring the same anesthetic management.

00160 Anesthesia for procedures on nose and accessory sinuses; not otherwise specified

00162 radical surgery

00164 biopsy, soft tissue

00170 Anesthesia for intraoral procedures, including biopsy; not otherwise specified

Coding Tip:

Diagnosis coding is important to substantiate coverage of code 00170.

Anesthesia provided in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting the teeth is

noncovered by Medicare.

J codes J0120–J9999 Drugs Administered Including Oral and Chemotherapy Drugs

K codes K0001–K9999 Durable Medical Equipment Prosthetics, Orthotics, Supplies and Dressings (DMEPOS)

L codes L0100–L9999 Orthotic and Prosthetic Procedures, Devices

M codes M0064–M9999 Medical Services

P codes P2028–P9999 Pathology and Laboratory Services

Q codes Q0035–Q9999 Miscellaneous Services

(Temporary Codes)

R codes R0070–R9999 Radiology Services

T codes T1000–T9999 Medical Services

S codes S0009–S9999 Commercial Payers (Temporary

Codes)

V codes V2020–V9999 Vision, Hearing and Speech-

Language Pathology Services

CRNA anethesia billing modifiers

Anesthesia Billing for CRNAs

When a CRNA is employed by the hospital and a separate anesthesia group is medically directing, reimbursement is shared in some cases, and non-existent in others – depending on several factors.  First, the method of reporting claims.  As previously mentioned, not all carriers recognize split claims or the HCPCS modifiers, and expect to receive only one bill for anesthesia services.  Unless the hospital billing department and the anesthesia group have a previous arrangement regarding the billing of anesthesia services, one should expect the “quickest claim filed” rule to come into play.  In this scenario, the first claim processed receives payment while the second claim is typically rejected, ignored, or denied as a “duplicate service”.   

      The second issue is that some carriers, such as Ohio Medicaid, will not pay separately for hospital employed CRNAs.  According to the January, 2005 Ohio Job and Family Service Physician Handbook, “Services of a hospital employed CRNA/AA are included in the facility.”   In some cases, Medicare offers small hospitals that employ only one CRNA a “pass through” billing option.  When this occurs, the hospital and/or CRNA receiving pass-through funding is prohibited from billing a Medicare Part B Carrier for any anesthesia services furnished to patients of that hospital. 

      It is also important to realize there is a distinct reimbursement difference between “supervision” and “medical direction.” While the terms are often used interchangeably by physicians, nurses, and office staff, they have two entirely different meanings.  Medical direction (the physician has met all the requirements, if applicable) effectively pays 100% of the claim.  Supervision, a claim that is filed with an “AD” modifier, indicates that the anesthesiologist was either involved with more than four concurrent rooms or cases (regardless of type of insurance) or failed to meet the medical direction steps in some states.  Medicare penalizes supervised claims by paying a maximum of four (4) units per case, providing the anesthesiologist was present for induction.  No time is allowed for any of the concurrent cases.    You may be surprised to learn that some carriers pay absolutely nothing when an AD modifier is reported.

      The AANA estimates that 80 percent of CRNAs work as partners in a care team environment with anesthesiologists. It is important that anesthesia billers have a clear understanding of how to bill for the services of CRNAs in their own state and recognize that not all payers require two claims.  Obtain state guidelines for each major carrier - Medicare, Medicaid, Blue Cross/Blue Shield, Work Comp and update annually. Remember - the only rules for reporting CRNA services to private insurance companies are the ones that you agree to in your contract.

   
QZ:    (CRNA modifier – pays 100%) non-medically directed CRNA services; CRNA is either working without medical direction or criteria was not fully met.   
QX:   (CRNA modifier – pays 50%) Medically directed CRNA services; the CRNA is being medically directed by an MD, who has met all required steps for medical direction. 
QK:   (physician modifier { used in conjunction with QX modifier} -  pays 50%) Medical direction of two, three or four concurrent procedures
QY:   (physician modifier { used in conjunction with QX modifier} -  pays 50%) MD is medically directing one CRNA  
AD:   (physician modifier { used in conjunction with QX modifier} -  pays maximum of four units or zero) Medical supervision by a physician of more than four concurrent procedures
Q6:  (physician modifier- doesn’t affect payment) Service furnished by locum tenens “physician”
Source:  HCPCS, 2005.

Hospital and ASC anesthesia billing

A majority of hospitals and ambulatory surgery centers are missing an opportunity to collect earned revenue associated with their anesthesia services.


For example, a hospital performing 5,000 cases per year, could be missing nearly $1,500,000 per year.

The evolution of the Outpatient Perspective Payment System (OPPS) continues to drastically change the landscape of healthcare reimbursement, both eliminating and creating revenue streams.
One such revenue stream commonly disregarded by hospitals is anesthetic revenue.  Due to the low dollar value and high volume nature of anesthetic transactions, it historically was difficult to achieve a return on investment of accounts receivable resources.

As a result of over a billion dollars in anesthesia and anesthetic reimbursement experience, we have successfully engineered a system to capture this anesthetic revenue stream without any additional cost to your facility.  Our service is not intrusive on any of your current billing processes, does not require additional hospital resources, and as a standalone service eliminates any administrative oversight.


Common result(s) from our service:

    * Increased revenue from anesthesia expert resources concentrating on reimbursement for drugs utilized in anesthesia.
    * Eliminate subsidization of anesthesia departments.
    * Minimized expenditures on drugs by accessing group discount purchasing organizations.
    * Monitoring distributor and producer pricing schedules for optimal inventory cost management.


To help your finance team gain a better value for the revenue impact we are referring; simply download our one-page survey and my team will be happy to complete a complimentary anesthetic revenue forecast along with a recoverable estimate for your facility's historic cases. 

Time truly is money, especially due to the fact that with every day that passes, your facility foregos the ability of capturing historic revenue, due to timely filing constraints of the third-party payors. 

If you have any questions and/or concerns regarding the survey or any of our services, please do not hesitate to call us directly at 877-358-9819 or email me via our info@anestheticbilling.com email address. 

Typical Scenario:  An inpatient procedure is completed and the hospital will bill their facility fee, the surgeon will bill their professional fee and the anesthesiologist will bill their professional fee.

Missed Opportunity:  The hospital's billing service assumes that all of the anesthesia related items are already included in those fees and not aware that many items are able to be billed individually.  Since these items are typically smaller dollar amount items, they fall under the hospital's write off amount (typically set around $500); thus never collected.

The Dollar Amount:  Take the number of cases your facility performs per year and multiply it by your own write off policy amount (typically $500 per case).  A portion of that dollar amount could be added back into your bottom-line this year.