Bogged Down with Clinical Documentation for Anesthesia using Complex, Tough, and Ever-Evolving Coding Systems ?

Are you unable to accurately and thoroughly document the surgical and anaesthesia processes and use the right combination of billing codes and modifiers for timely and proper submission of medical insurance reimbursement claims ?

Are you experiencing nightmares due to lack of awareness of multiple ranges of anaesthetic reimbursement guidelines adopted by different insurance companies ?

The era of inconsistent, inaccurate and incomplete Anaesthetic Documentation: According to a survey conducted by Academic Health Sciences Centre, Montreal, Quebecmany of the preoperative and intraoperative variables which are important for documentation of anaesthesia are recorded inconsistently and incompletely.

Why the need for Precise and Thorough Clinical Anaesthetic Documentation ?

a• A thorough and precise clinical anaesthetic documentation helps in capturing the right combination of the diagnostic/treatment code coupled to the appropriate modifier to depict the actual surgical scenario under which operations are performed.
b•  Such an optimal combination of codes and modifiers, along with justified need for the treatment and approved care, helps in sending the correct medical reimbursement claims to insurance companies for speedy receipt of claims, without denial of claims and need to resubmit and follow up the claims.
c.•  The cumulative process results in maximizing revenue and profits.
To survive and prosper, you need to enhance documentation, boost coding accuracy, decrease denials, and safeguard payments.

Other plus points of Medical Documentation :

Medical documentation of procedures and events while a patient is under anaesthesia, serves as patient-safety tool, medico-legal document, quality assurance analysis, and dictates the outcomes in medico-legal cases. The record warrants attention to ensure its optimal contribution to patient care.

Correctly appending the appropriate modifier to the diagnostic, procedure and treatment code is critical, according to Marvel J. Hammer, an accomplished professional with considerable years of experience both in the business and medical fields.

For an anaesthesiology practice to get reimbursed fully and properly from the insurance agencies for its work, anaesthesia coders must be fully conversant of the intricacies of the differences between a plethora of anaesthesia processes, for instance, conscious sedation, monitored anaesthesia care (MAC), general anaesthesia, and so on. In addition, they must be fully aware of the special modifiers to be reported.

Why the urgency and criticality ? There are more than half-a-dozen issues :

a•  Improvement in anaesthesia documentation is critical, since documentation can make or break up the business of anaesthesia providers.
b•  In this economic scenario, anaesthetics have to cope-up ever-increasing patient rush, federal and state health regulatory stipulations, and quality care at affordable costs.
c• On and after October 1, 2014, entities covered under the Health Insurance Portability and Accountability Act (HIPAA) are required to use the ICD-10 code sets in standard transactions adopted under HIPAA. The HIPAA standard health care claim transactions are among those for which ICD-10 codes must be used for dates of service on and after October 1, 2014. This implies that the in-house billing and coding staffs are aware of these changes.
d• ICD-10 diagnosis codes have different rules regarding specificity and providers/suppliers are required to submit the most specific diagnosis codes based upon the information that is available at the time.
e• In addition, ICD-10 Procedure Codes (PCs) will only be utilized by inpatient hospital claims as is currently the case with ICD-9 procedure codes.
f• For instance, many carriers have special policies regarding reimbursement for anaesthesia, which are surgical/treatment-specific such as during endoscopy. This needs familiarity with respective insurance companies to ensure that the documentation supports what the insurer requires.
g• There is a need to be up to date with the latest coding guideline, and the ability to pinpoint small differences when the descriptors to some of the most common codes change.

3 Examples of intricacies of accurate, exhaustive clinical documentation :

a• Every detail supporting moderate sedation is crucial, considering how closely insurance companies audit the medical necessity and authorization.
b•  Correct calculation of time for which anaesthetic services, including time for which the surgeon is present, and so on, are provided.
c•  Assigning the correct add-on code when the anaesthetic service lasts longer than 30 minutes (each additional 15 minutes intra-service time), taking care to match the add-on code with the appropriate base code.

The way out of this impasse :

Relax….and Rest Assured and get rid of your nightmares by outsourcing your documentation, coding and billing worries to MedicalBillingStar, an established, experienced one-shop outsourcing vendor.

Why MedicalBillingStar ?

Anesthesia billing is completely unique compared to other specialties and MedicalBillingStar with a commitment to excellence has been billing for anesthesia practices has been billing for anesthesia practices. We streamline documentation, resulting in more efficient billing, and most importantly, better patient care and engagement which ensures that the necessary data is accurate. We offer a sophisticated customized EHR platform for anaesthesiologists and our solutions facilitate secure distribution of information and shortening the reimbursement cycle for anaesthesiologists by ensuring that all required data is present and complete, thus eliminating claim rejections.