Anesthesia Start and Stop Time: Do All Providers in Your Group Apply the Same Definition?

March 23, 2009

It is without question that anesthesia time is one of the most critical elements in anesthesia billing making it an important compliance focus area for any anesthesia group. Given the expected increase in Medicare and Medicaid audit activity, we encourage anesthesia groups to periodically revisit the definition of anesthesia time. How long has it been since your anesthesia group has taken a careful look at how each individual anesthesiologist or CRNA (hereinafter collectively referred to as “anesthesia provider”) is accounting for anesthesia start and end times?

According to federal regulations (42 CFR Section 414.46), anesthesia time only includes the time when the anesthesia provider is present with the patient. More specifically, anesthesia time starts for billing purposes when the anesthesia provider begins to prepare the patient for anesthesia services and ends when the anesthesia provider is no longer providing anesthesia services to the patient. The anesthesia provider is considered no longer furnishing services for the purposes of time when the patient may be safely placed under post-operative care.

Although the anesthesia time definition would allow time to begin preoperatively as long as the anesthesia provider is actually preparing the patient for anesthesia services, it is important to keep in mind that Medicare and other payors do not expect to see extended periods of pre-operative time. It is also clear that the start of anesthesia time should not begin due to the placement of an invasive monitoring line or post-operative pain block in the pre-operative holding or equivalent area prior to induction of the patient. Moreover, services that are included in the anesthesia base unit cannot be counted towards time. The anesthesia base unit is defined to mean the value for each anesthesia code that reflects all activities other than anesthesia time. These activities include usual pre-operative and post-operative visits (including the pre-anesthetic exam and evaluation), the administration of fluids and blood incident to anesthesia care, and monitoring services.

Medicare also permits discontinuous time in certain situations. Specifically, in counting anesthesia time, an anesthesia provider can add blocks of anesthesia time around an interruption in the furnishing of anesthesia as long as the anesthesia provider is furnishing continuous anesthesia care within the time periods around the interruption. According to the government’s commentary when the discontinuous time provisions were added to the regulations, the discontinuous time provision was enacted to take into account those instances in which there is a break in the continuous presence of the anesthesia provider in providing the “normal course” of administration of an anesthetic (i.e., establishment of venous access; acquisition of initial monitoring information; induction of anesthesia; maintenance of anesthesia; and conclusion of anesthesia attendance).

For example, discontinuous time could occur when a regional anesthetic technique is used for the surgery, resulting in a break between induction of anesthesia and maintenance of anesthesia in which the patient can be safely observed by non-anesthesia personnel. Moreover, a break in anesthesia time could occur when a patient is being prepared for anesthesia in the operating room for induction and the surgeon is delayed. In such cases, the anesthesia provider may determine that it is appropriate to leave the patient under the observation of others until the surgeon is present and it is appropriate to proceed with induction.

Notably, however, it is not expected that the use of the discontinuous time provisions would be routine. It is also important to highlight that it would not be appropriate to use the discontinuous time provisions to report time spent placing invasive monitoring lines or post-operative pain blocks in a holding area prior to surgery as these services are separately payable procedures and do not represent breaks in the normal course of the administration of the anesthetic for the surgical case.

To the extent any anesthesia provider in your group routinely captures extended periods of preoperative or post-operative time, the group should take a careful look at such practice as the anesthesia provider may be capturing activities that would not qualify to be captured in anesthesia time. We encourage groups to ensure that each provider has a full understanding of anesthesia time and for the group to periodically visit this issue to oversee consistency among the group providers.

As always, we welcome readers’ questions and comments.

With best wishes,

Tony Mira,

President and CEO