Providing anesthesia services in areas remote to the operating room (O.R.) has become a way of life for most anesthesiology groups. Today this is commonly called “off-site anesthesia,” or at M.D. Anderson Cancer Center (MDACC), it is called “out of sight” anesthesia.

Each institution will have different requests for such anesthesia. Ours include GI endoscopies, central venous line placements specifically for chemotherapy, computerized tomography and magnetic resonance imaging, bone marrow aspirations, pediatric spinal taps for patients with various blood dyscrasias, radiotherapy treatments and miscellaneous invasive and diagnostic procedures.

Monitored anesthesia care (MAC) has been a subject with many definitions. The 2004 ASA Relative Value Guide includes the following statement:

Monitored anesthesia care is a specific anesthesia service for a diagnostic or therapeutic procedure. Indications for monitored anesthesia care include the nature of the procedure, the patient’s clinical condition and/or the potential need to convert to a general or regional anesthetic.

Most, but not all, procedures may be found in either the ASA Relative Value Guide or CROSSWALK™. The major issue in billing for off-site anesthesia services is documenting necessity. A unique anesthesia record has been developed for off-site anesthesia procedures, which has indications that can be checked off. Some of the indications we use are:

Central Nervous System:
• Pre-senile dementia
• Drug-induced mental disorders
• Major depressive disorders or schizophrenia
• Hysteria, unspecified (includes fear of pain)
• Phobic disorders, unspecified (claustrophobia)
• Transient cerebral ischemia
• Cerebrovascular disease, other and ill-defined

Cardiovascular:
• Hypertensive heart disease, malignant, benign, unspecified
• Ischemic heart disease, acute or subacute forms
• Old myocardial infarction
• Coronary atherosclerosis, bundle branch block, other and unspecified cardiac dysrhythmias
• History of atrial or ventricular fibrillation or flutter

Pulmonary:
• Bronchitis, acute, chronic or unspecified
• Chronic airway obstruction
• Radiation-induced pulmonary disease, acute or chronic

Other:
• Acquired hypothyroidism
• Electrolyte imbalance
• Morbid obesity
• Adverse effects not classified elsewhere
• Opioid, barbiturate, cocaine, cannabis, amphetamine or unspecified drug dependence
• Combative patients
• Patients with low pain thresholds or severe pain
• Chronic liver disease or cirrhosis
• GI tract hemorrhage, unspecified

In some states, including Texas, Medicare carriers employ their own list of indications required for payment.

Currently most of the off-site anesthesia provided includes the use of propofol, which results in general anesthesia. With the use of general anesthesia, however, we have had to use the same criteria for discharging these patients as the patients in the postanesthesia care unit. In reviewing denials for coverage, there have been few denials when the appropriate documentation has been provided.

At MDACC, there is an O.R. dedicated for pain procedures. Since anesthesia for these procedures is done in a regular O.R., there have been few problems with reimbursement as long as appropriate documentation is provided.

When providing care for these off-site procedures, it is necessary to perform these seven steps (if medically directed) or six steps (if personally performed). For your review, these steps are:

1. Perform a preanesthetic examination and evaluation

2. Prescribe the anesthesia plan

3. Personally participate in the most demanding procedures in the anesthesia plan, including induction and emergence

4. Ensure that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist (obviously for medically directed)

5. Monitor the course of anesthesia administration at frequent intervals

6. Remain physically present and available for immediate diagnosis and treatment of emergencies

7. Provide indicated postanesthesia care

In the “Medicare Claims Processing Manual,” the following statement is found:

Monitored Anesthesia Care — Pay for reasonable and medically necessary monitored anesthesia care services on the same basis as other anesthesia services. Instruct anesthesiologists to use modifier QS to report monitored anesthesia care cases. Monitored anesthesia care involves the intraoperative monitoring by a physician or qualified individual under the medical direction of a physician or of the patient’s vital physiological signs in anticipation of the need for administration of general anesthesia or of the development of adverse physiological patient reaction to the surgical procedure. It also includes the performance of a pre-anesthetic examination and evaluation, prescription of the anesthesia care required, administration of any necessary oral or parenteral medications (e.g., atropine, demerol, valium) and provision of indicated postoperative anesthesia care.

Payment is made under the fee schedule using the payment rules in subsection B if the physician personally performs the monitored anesthesia care case or under the rules in subsection C if the physician medically directs four or fewer concurrent cases and monitored anesthesia care represents one or more of these concurrent cases. [sic].

We also attempt to document through the scheduling office that the physician doing the off-site surgical/diagnostic procedure requested anesthesia services. When the schedule is published, the physician who requested the service is listed. It is important to document the “reasonable and medically necessary” portion of the statement. We also have found it necessary on occasion to educate compliance personnel, coders and carriers about the ASA’s “Continuum of Depth of Sedation; Definition of General Anesthesia and Levels of Sedation/Analgesia.*”

This has been an ongoing learning curve for us at MDACC. On some days, we simultaneously provide these services at six off-site areas for up to 35 patients. Inefficiency in scheduling is the norm rather than the exception because in most areas, several providers perform the services sequentially rather than just one. These areas traditionally have not run on a schedule so O.R. scheduling as we know it is a foreign concept.

The trend for these services continues to rise because patients expect all procedures to be pain-free. Not surprisingly more and more anesthesiologists request total intravenous anesthesia, or TIVA, for their own diagnostic procedures.

First document well, and be prepared to educate your own department, coders, billing and compliance personnel and insurance carriers. Understand your denial reports so that corrections can be made to avoid future denials or to challenge the denials. Challenge denials on a timely basis, currently 120 days according to Medicare standards. Choose the cases to be challenged carefully, and use the challenge to educate the carriers.

Another area of non-O.R. anesthesia billing is billing for anesthesia consultations. What is the difference between a preoperative evaluation and a consultation? From a billing standpoint, an anesthesia preoperative evaluation is part of the global fee, whereas the global fee does not cover an anesthesia consult. To bill for a consultation, however, there must be a documented request for the anesthesiologist to evaluate the patient and the medical necessity for the consultation as well as documentation of the three key components: history, examination and medical decision-making. Either the surgeon or anesthesiologist can document the request. Often the medical necessity is to determine if the patient is in his or her “optimal medical condition” or “acceptable” condition to undergo the planned surgical procedure. A consultation note usually includes a chief complaint, history, past surgical history, past medical history, review of systems, physical examination, assessment and plan. Although sending a copy of your consultation note or a summary note of the consultation to the referring physician is not required for billing, usually a note is sent to communicate with the referring physician.

There are four types of consultations: 1) office or other outpatient, 2) inpatient, 3) established inpatient and 4) confirmatory consultation. The first three types of consultations are most applicable to anesthesia. To code the anesthesia consultation visit properly, the person coding must know if the patient is an inpatient or an outpatient. The relative value units are the same for each of the five levels of care for the inpatient and outpatient consultation. If the patient requires a follow-up visit, though, the relative value units are higher for an inpatient than for an outpatient. For full descriptions of each level of care, consultation requirements and codes, please refer to Current Procedural Terminology™.

We have a unique situation for anesthesia consultation billing at MDACC. A significant number of our patients are geriatric patients with multiple comorbid conditions who have recently received chemotherapy and/or radiation treatments and are scheduled to undergo a complex or lengthy surgical case. The medical necessity for the consultation can be justified by the patient’s medical condition. Also our surgeons give us a written or verbal request up to a month in advance of surgery for our anesthesiology group to evaluate and optimize their patients. In the clinic, the anesthesiologist takes a history and performs a physical examination of the patient, which includes assessment of the vital signs, assessment of the airway and auscultation of the heart and lungs. Furthermore the anesthesiologist makes medical decisions based on the elicited history and physical examination along with a review of the patient’s chart and available outside records to determine if the patient is in his or her optimal medical condition.

To determine if the patient is in his or her optimal medical condition, the following questions should be taken into account:

1. What is the status of the patient’s health?

2. How severe is each illness or medical condition?

3. How does each illness affect or increase the operative risk for the patient?

4. How urgent is the surgery?

5. Will delaying the surgery to treat the patient’s illness lessen the patient’s operative risk?

6. If the illness does not require delaying surgery, what changes need to be made perioperatively to improve the patient’s management?

7. Has the patient stopped taking anticoagulants for an adequate period of time prior to surgery?

Optimization of patients at MDACC includes ensuring that the appropriate medications are taken the morning of surgery, writing prescriptions for antibiotics, pulmonary bronchodilators, beta-blockers and anxiolytics as well as ordering cardiac stress tests, echocardiograms, chest X-rays and laboratory studies. Occasionally patients have medical conditions that require specialized expertise. These patients are referred to the appropriate physician for optimization prior to surgery. Also patients in our clinic who need emergent care prior to surgery are sent to the emergency room. Some of our patients have their surgery cancelled or postponed because of information that the anesthesiologist brings to the attention of the surgeon.

Some patients require a follow-up visit after the consultation. A patient can be billed for a follow-up visit. For example if the patient needed a stress test prior to surgery and returns to the clinic after completing the stress test to be re-evaluated for surgery, then this patient can be billed for a follow-up visit provided that two out of the three key components (history, examination and medical decision-making) are documented. The codes and relative value units are different for an inpatient versus an outpatient follow-up visit, however. For an inpatient follow-up visit, an established patient is coded 99261 to 99263 (depending on the level of care and documentation) under follow-up inpatient consultation. An outpatient follow-up visit for an established patient is coded 99211 to 99215 under office or other outpatient services. The relative value units are higher for a follow-up visit for an inpatient.

What period of time must elapse between visits before a patient can be billed for a new consultation? Three years must elapse between the initial consultation and the next evaluation by an anesthesiologist in the same group before the consultation can be billed as a new consultation. If an anesthesiologist in the same group evaluates the patient within the three-year window, he or she is billed as an established patient.

Billing effectively and following the rules requires a great deal of time and education for anesthesiologists, nurse anesthetists, anesthesiologist assistants, coders, billers and carriers concerning the documentation necessary to justify the indications. Billing for pre-anesthesia evaluation requires familiarity with evaluation and management codes, which are used in general by anesthesiologists practicing pain medicine. It seems that the demand for anesthesia services outside the main operating room will continue to escalate. All efforts at getting paid for providing these services will prove worthwhile in your practice. Much of the policy on these issues is determined by local carrier decisions, which are not binding on national coverage decisions.

A special thanks is owed to Marc A. Rozner, M.D., Ph.D., and Susan M. Feather, M.D., for their hard work in establishing anesthesia consultation billing at MDACC.

James F. Arens, M.D., is Professor and Chair, Department of Anesthesiology, M.D. Anderson Cancer Center, Houston, Texas.

Andrew MacLachlan, M.D., is Assistant Professor, Department of Anesthesiology and Program Director, Perioperative Services, M.D. Anderson Cancer Center, Houston, Texas.