The Winning Strategy for Billing Invasive Monitoring

Kelly D. Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I

Perfect Office Solutions, Inc., Leesburg, FL

When the ASA Relative Value Guide (RVG) was first developed in the 1970s it established a significant precedent with regard to what services could be billed as incidental to an anesthetic. The guide established the concept of "invasive" as the critical criterion.

Arterial artery catheters, known as A-lines; central venous catheters; and Swan-Ganz catheters were specifically identified as non-bundled services because they were used for particularly sick patients with a high risk factor and were invasive. Some years later transesophageal echocardiography (TEE) was also added to the list, even though it was not technically invasive. One might also say that ultrasonic guidance for vascular line placement has also been lumped into the same category.

This distinction has served the specialty well ever since, especially since virtually all payer fee schedules include payment for these "surgical" services, i.e., the placement of such devices. Where anesthesia providers need to be careful, though, is in ensuring that their clinical documentation completely supports a charge for each service. The requirements and exclusions are specific.

The Nuances of 'Who'

The first question is always who provided the service? This might seem obvious, but it is not always clear whether the anesthesia provider simply took advantage of an in situ catheter. In some facilities, surgeons or a perfusionist may place catheters for monitoring cardiovascular function, in which case the placement of such devices is a non-billable event for the anesthesia provider.

If more than one anesthesia staff member is signed into the case—a combination of anesthesiologist, teaching anesthesiologist and resident, certified registered nurse anesthetist (CRNA) or student registered nurse anesthetist (SRNA)—documentation must clearly show who placed the line. Teaching rules have special requirements for documentation of physician participation, and although a GC modifier indicates "when the service has been performed in part by a resident under the direction of a teaching physician," there is no modifier to report an SRNA placing a line. Indeed, no payment is made under Medicare Part B for services provided by an SRNA. This is important to keep in mind if an SRNA solely places an arterial line, for example, without the teaching CRNA's or anesthesiologist's documented involvement.

Although an auditor is not likely to request all the records prepared by the various staff in an operating room, they might if there were a question regarding the accuracy or completeness of the anesthesia record. Ideally, any notes prepared by the OR staff should conform to the anesthesia record.

Why and How?

Why and how was such monitoring administered? Unlike the calculation of the anesthesia charge itself, the placement of invasive monitoring is billed as surgical services. No time is involved. And payment is based on a surgical fee schedule. Although a full operative report is not necessary or expected, the medical record documentation for these ancillary services must explain the details of the procedure and its relevance to the patient's condition.

While the advent of electronic anesthesia records (EARs) has helped tremendously with clear documentation of these services, paper anesthesia records do not typically have enough room under the Remarks or Comments areas to fully describe ancillary services. The best practice for anesthesia providers is to utilize a separate procedure note, which will allow enough room to include documentation required under The Joint Commission's Universal Protocol (see resources at the end of this article).

This protocol requires a date of service, patient's name and consent, start and end time of the procedure, medical necessity (reason for insertion), a description of supplies used, a procedural "timeout" (correct patient identity, correct site, procedure to be done), patient's positioning, preparation for the procedure, confirmation of using sterile technique (sterile gloves, gown, hat/cap, mask, full body drape and, if ultrasound is used, sterile gel and probe covers), confirmation of the insertion site, a full description of the procedure (including whether the line was removed with the tip intact, when applicable) and whether ultrasound was utilized. The form must also include the anesthesia provider's legible signature.

Keep in mind that documentation of the use of ultrasound alone is not sufficient. According to CPT? non-obstetrical ultrasound coding guidelines, "Use of ultrasound, without thorough evaluation of organ(s) or anatomic region, image documentation, and final, written report, is not separately reportable." Although it does not normally need to be turned in with your billing records, a retrievable image must be available in the medical records, along with the signed procedure note describing the use of ultrasound, when applicable.

Clearly, a check box on the anesthesia record under monitors and equipment, or "Swan-Ganz" written in the remarks section, does not meet these Universal Protocol standards.

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