Author: Tony Mira
How do anesthesia providers account for time spent in cases that contain a delay on either the front end or back end? Today’s alert provides recommended solutions for such scenarios.
It happens occasionally. A teacher waits for a delayed parent to pick up the last remaining child at the end of a school day. The babysitter demands another ten because you arrived home an hour later than arranged. These temporal disruptions in our otherwise routine schedules are not supposed to occur, but they inevitably do. Now what? That’s what many anesthesiologists and anesthetists would like to know. After all, they, too, are not immune to the caprices of time.
Disturbance in the Force
The surgical schedule is like a well-oiled machine, with patients being ushered in and out on a timely basis—indeed, on a precisely calculated basis—with little room for error. Utilization experts and OR managers are quite adept at determining which cases will typically take X number of minutes. As a result, they know when to begin prepping the next patient and thereby execute an efficient turnover rate. It’s not quite an assembly line process where robotics and automation provide unquestioned predictability, but healthcare facilities do their best to accurately anticipate case timing and transition.
The problem, of course, is that unforeseen events occur. They are going to happen. A surgeon arrives 15 minutes late because a previous case ran unexpectedly long, or a surgery had to be canceled because the patient developed an unforeseen issue, or perhaps the recovery “time in attendance” had to be extended due to a lack of appropriate staff. Stuff happens. So, what does that mean for the anesthesia provider in terms of billing opportunities? Let’s take a look at a couple of scenarios.
Delayed at the Start
No one likes a delayed start time. Whether we’re talking about a 5-minute delay of a conference call or a 30-minute delay in a concert performance, people get annoyed at such occurrences. And the reason why is because people—especially busy people—hate wasting time! What’s the old saying? Time is . . . money? When it comes to business—especially the business of anesthesia—that is most certainly the case. You are paid, in part, for the number of minutes you’re able to spend on a case. Well, what happens when you are ready to begin a case but something untoward occurs at the outset that leaves everyone hanging?
Let’s say you’ve performed the pre-anesthesia assessment, you’ve washed and scrubbed, and you are now with the patient in the pre-op holding area (PHA) administering Versed in preparation for the beginning of the case. You next hear that a certain piece of equipment required for the successful conduction of the procedure is on the fritz. The time it takes to lay hold of a working replacement creates a delay of 20 minutes. Obviously, in this scenario, there is not much you can do. Unless you decide to stay with the patient during the 20-minute delay, and there is medical necessity for doing so (based on the Versed administration), you will be unable to bill for this unexpected time delay.
But what if you were already in the OR with the patient when it was learned that the case would face a 20-minute delay due to the equipment failure? We’ve always said that, once you’re in the OR with the patient, the anesthesia clock can run. (There is one exception to this that we’ve covered in previous alerts: when you place a post-op pain block or invasive line in between the anesthesia start time and anesthesia induction time.) So, what happens with this otherwise tried and true rule in the event of a case delay? Here are some possible ways to proceed:
- If the patient has already received some type of sedation before announcement of the case delay, and the delay is not sufficiently long to justify removing the patient from the OR, then it would be permissible to count the delay time where you remain with the sedated patient until the surgery can begin. In such an event, we encourage you to drop a note in the comments section of the record explaining the circumstances of the delay.
- If the delay is long enough to allow the patient to recover from the effects of sedation and the patient is removed from the OR, you could bill time in attendance with the patient until the patient is turned over to other non-anesthesia personnel. When the case is resumed, you can start the anesthesia clock again once you reenter the OR with the patient.
There may be other scenarios other than those listed above that may occur. The key is to err on the side of caution in billing anesthesia time in such situations. Generally, if there is medical necessity for you to be present with the patient during these case delays, that represents care time that a health plan may deem to be appropriate and thus billable.
Delayed at the End
With the advent of increasing case loads and/or staff shortages during these days of COVID, we are receiving an increasing number of reports from our clients of cases where the anesthesia provider is being forced to remain with patients either in the OR (because the PACU is full) or in PACU (because of a lack of personnel in that unit) beyond the point when they normally would. So, what is the provider to do in such a circumstance?
Unless a particular payer has provided written guidance to the contrary, we believe it is entirely appropriate to bill time in either location (OR/PACU) reflecting your continuing presence with the patient caused by delays due to the above-referenced circumstances. Some of you may recall that the Medicare Claims Processing Manual (MCPM), Ch 12, Sec 50, actually provides a definition of anesthesia stop time. In addressing anesthesia time, generally, the MCPM goes on to say the following:
. . . 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.
You are, therefore, allowed to bill anesthesia time until transfer of care. There is no exception to this allowance listed in the MCPM to account for delays that you occasionally encounter. Consequently, if your care transfer time is delayed due to the temporary unavailability of PACU space or staff, meaning there is no one to whom you can turn the patient safely over, then you can bill through that time. Again, you will want to provide a note in the anesthesia record explaining why you had to spend an inordinate amount of recovery time with the patient.
Ultimately, it will be up to the payer to determine how much of this time is reasonable for reimbursement purposes. Your documentation of the extenuating circumstances becomes especially pertinent when considering that, some time ago, Medicare conducted a study of typical time spent in PACU. They determined that the average anesthesia time in recovery is 7 minutes. That doesn’t mean you are forced to stick to that precise amount. Every case is different, and Medicare knows that; however, it does reinforce the fact that Medicare is watching for habitual outliers as to recovery time. If, due to current circumstances at your facility, you are routinely forced to spend extended recovery time with your patients, it may raise red flags with auditors. They may not wish to reimburse you the full time you have claimed. Indeed, despite the above MCPM excerpt, at least one Medicare administrative contractor (years ago) stated that 15 minutes is the absolute limit for billing post‐surgery anesthesia time—regardless of PACU issues that cause an extended wait. So, ultimately it depends on whether or not the payer (a) has a policy on this, or (b) agrees with the medical necessity of your extended time claim.