Maximizing Medical Billing

By July 6, 2018 No Comments

As the interaction between health payers and hospitals become increasingly complicated, it is necessary for anesthesia management companies to focus on medical billing as a central tenet of the practitioner experience. Medical billing refers to the complex set of codes that a healthcare clinician must submit to the hospital’s electronic medical records (EMR) system in order to (a) record in a standardized system the services and procedures rendered during a patient’s stay in the facility and (b) apply for reimbursement from the patient’s payer or, if uninsured, by the patient him/herself out of pocket. The Center for Medicare and Medicaid Services (CMS) provides regular rule updates regarding medical billing. Similar to coverage policies, the standards for medical billing under CMS often directly impact that of commercial payers. Therefore, when examining the issue of medical billing it is often useful to base management on CMS guidance.

As a precursor for utilizing the correct code in medical billing, it is essential to identify the clinician who performed the service or procedure on the patient. Furthermore, the billing code should also distinguish between the anesthesia practitioner from the following list: anesthesiologists, certified registered nurse anesthetists (CRNAs), anesthesiologist assistants (AAs), registered nurses (RNs), or nurse practitioners (NPs) — who performed the procedure. CMS describes four categories to guide clinicians and administrators with making the distinction of the act. The four categories are: teaching, personally performed, medically directed, and medically supervised. “Teaching” and “personally performed” are fairly cut and dry. However, the distinction between medically directed and medically supervised is often confused, causing changes in billing and therefore reimbursement results. As per CMS, the “medically directed” designation indicates a higher level of involvement from the most senior practitioner than that of the “medically supervised” category. For example, an anesthesiologist who performs the preoperative exam and evaluation, prescribes the anesthesia medications, and/or personally performs complicated parts of the procedure during surgery would clearly have contributed above his/her role as supervisor. Therefore, in this case the billing code would fall under “medical direction”. Here’s another example: an anesthesiologist and CRNA are working on the same case team and the anesthesiology is highly staffed (defined as participating or leading on more than four cases). The anesthesiologist may advise on the anesthesia plan as developed by the CRNA, and the CRNA is responsible for enacting all the parts of the project plan, including anesthesia administration and post-op care. In this case, this code would be defined in the medical billing scenario as a medical supervision case, reflecting the lack of physician involvement and increase CRNA leadership at every stage of the anesthesia episode.

In addition to distinction of practitioner roles in the medical episode, a crucial aspect of accurate medical billing rests with meeting rigorous documentation requirements. Documentation should at a minimum include timing, clinician notes, dosage and administration, medical equipment usage, and a medical assessment. Moreover, any documentation will need a verified signature from the surgeon or most senior practitioner present during the surgery. This is to prepare for an event that the insurance claim is rejected: in response, medical billing administrative professionals could then refer back to the verified case notes to identify the specifics of a case. Therefore, it is essential for medical documentation to be comprehensive, specific, accurate, and up-to-date.

Luckily for anesthesiologists, CRNAs, AAs, and additional anesthesia providers, healthcare technological developments are actively being developed to facilitate the documentation process for clinicians. A study in the peer-reviewed journal Anesthesiology described a computer software that can automatically parse through EMRs and alert clinicians if the event that there appears to be an error. The researchers found that the system not only reduced the number of unbilled records and the median time for clinicians to fix documentation errors, but it also increased the anesthesiology department revenue by capturing formerly missed reimbursement. The efficacy and cost benefits of rigorous documentation as elucidated in this study underscores the importance of high standards in billing.

Anesthesia management companies should continue to refine medical billing as they improve standards of care, referring to novel rules, regulations, and mechanisms to increase accuracy and efficacy on a global scale.