Author: Tony Mira
Ancillary procedures, such as postoperative pain blocks and invasive lines, are an important part of most group practices, but many may not realize that there are time-based rules tied to these services. As these rules can be a bit complex, the following article is provided.
This is the last in our recent series of articles focusing on anesthesia time. In this part four of our primer, we will delve into what may be the most surprising, confusing and downright frustrating element of time compliance for the anesthesia provider. Many are not even aware of this element or the rules surrounding it. Nevertheless, it is a reality that must be accounted for in many, though not all, anesthesia cases. Today, we will be addressing anesthesia time in connection with separately paid surgical procedures, such as invasive line and postoperative pain block placements.
Origin of The Rule
In the May 2007 edition of the CPT Assistant (Volume 17, Issue 5), the American Medical Association (AMA) was asked a question, which flowed along the following lines: do I have to deduct anesthesia time during the placement of an invasive line (e.g., a-line, CVP, Swan-Ganz) or postoperative pain block? The answer provided by the AMA was essentially “yes”—if such placement occurs prior to “induction of the primary anesthetic.”
Since the time of this instruction, confusion has reigned in the anesthesia world because many have not been aware of this rule or have been uncertain as to what must be done to sufficiently comply with it. That being the case, let’s take a deeper dive.
Specifics of The Rule
As we learned in part one of this primer, anesthesia time can begin once you’re in the OR with the patient. That has historically been deemed axiomatic and automatic. If you’re in the OR, the anesthesia clock is running. That’s why many anesthesia practices use their “OR In” time as their default anesthesia start time.
However, based on the wording of the 2007 AMA rule, there is now an implication that you can be in the OR, and yet still be forced to deduct anesthesia time. Here’s an example. Let’s say you enter the OR at 0800, place a postoperative pain epidural a few minutes later, and then induce the general anesthetic a few minutes after that. Here you have a strange scenario where you are in the OR—where anesthesia time is normally and automatically running—but you must now deduct from your anesthesia time those minutes it took you to place the pain block. Why? Because you placed the block prior to the general, i.e., the “primary anesthetic.”
Now, if that same block were placed in the preoperative holding area, there is no issue, because you’re typically not going to be billing anesthesia time in the holding area to begin with (with the exceptions we mentioned in part one of this primer). So, typically, the only occasion when this time deduction rule will come into play is when you’re in that small temporal window between the anesthesia start time and the induction time.
Complying with The Rule
So that we can be compliant with the AMA time rule, we ask our clients to abide by the following documentation protocol:
When placing a separately billable pain block or invasive line between the anesthesia start time and the induction time, we need the provider to list three additional times on the record:
- Induction time (of the primary anesthetic, i.e., not Versed time)
- Start time of placement
- Stop time of placement
When placing a separately billable pain block or invasive line before the anesthesia start time or after induction, we need the provider to add one of these two attestations next to the line or block documentation on the record:
- “Placed before start time”
- “Placed after induction”
To be clear, if we see a pain block or invasive line on the record and the above documentation protocol is not fully met, we will send a request back to the provider asking him/her to provide the missing time(s) or attestation. Most of our clients are aware of these requirements and are complying, and we greatly appreciate your assistance with these time notations.
Those using an electronic medical record (EMR) may rightly point out that, while the EMR contains a seamless way to list an induction time and a placement start time, it may not have the same functionality to denote a placement stop time. In these instances, we encourage groups to work with their facility to add such functionality to the system. Until that fix is made, we recommend providers utilize other options afforded by the EMR to list the placement stop time, where applicable, such as “quick note” or other free text capabilities.
Understanding the Rule
The AMA’s response in 2007 made it clear that billable time is not associated with a separately billable procedure, such as the placement of an invasive line or pain block. That’s why you never could bill for the time it took you to perform such placements when the placement occurred in the holding area or after emergence. The reason why the AMA allows you to bill anesthesia time after induction of the primary anesthetic appears to be due to the following rationale:
- When you are performing a postoperative pain block or invasive line you are technically acting as a surgeon, as these procedures fall under type of service (TOS) 2, “surgery,” whereas anesthesia services fall under TOS 7, “anesthesia.”
- The reason the AMA allows you to bill anesthesia time during the placement of a pain block or line after induction is because you are simultaneously administering anesthesia. You’re not just wearing your surgeon’s cap, you are also wearing your anesthesia cap, thus the anesthesia time can run.
Given this thinking, there would seem to be a way to avoid the carving out of placement minutes between the anesthesia start time and induction. How? By ensuring that the person performing the pain block or invasive line is someone other than person providing the ongoing anesthesia service.
In 2011, that very scenario was put to the AMA by an anesthesia compliance attorney. While certain legal restrictions prevent us from passing on the AMA’s written response, we believe we can confidently assert that anesthesia time—occurring between the anesthesia start time and induction time—would not have to be deducted for line or pain block placement under the following circumstances:
- Where a personally performing anesthesia provider acts as the attending throughout the case, and where the attending’s partner or other group member places the line or block.
- Where a medically directed CRNA is present with the patient throughout the case, but where the medically directing anesthesiologist is the one who comes in to place the line or block (only for those jurisdictions where medically directing doctors are allowed to place pain blocks or lines without breaking medical direction).
Not having to deduct the minutes it takes to place a pain block or invasive lines from total anesthesia time makes perfect sense under these circumstances as in each scenario above someone is always wearing the anesthesia cap throughout the case. In these situations, the provider would not need to list the placement start and stop times or induction time, as long as the record makes it clear that a provider other than the individual who is present with the patient throughout the case is the one performing the separately billable procedure.