We recently published a whitepaper, titled “A Discussion of the Variation in Anesthesia Start Time Documentation” to some of our partners. It explores the definition of anesthesia start time, and the differences in the definition between documenting (or billing) start time and actual pre-operative patient care.
Definition of Anesthesia Start Time
CMS defines the Anesthesia Start Time as the time when the attending physician started continuous care of the patient.
Under the rules for Payment at the Medical Directed Rate, physicians qualify for two, three, or four concurrent cases — assuming they provide certain activities, such as performing a pre-anesthetic examinatiion, monitors the course of anesthesia administration at frequent intervals, and remains physically present and available for emergency care (among others).
Why Anesthesia Start Time Matters
The CMS rules continue and state: “However, the medical record must indicate that the services were furnished by physicians and identify the physicians who rendered them.”
While this may seem obvious, it is during the preoperative assessment period where we see a good deal of variation in the documentation and application of these billing regulations.
What We’ve Found
Our thorough analysis of the difference between anesthesia start time (AST) and patient in room (PIR) time stamps varies considerably from site to site.
Why is this? Different sites apply the requirements differently — you’d expect a few minutes difference between AST (in the preoperative holding area) and PIR (in the OR), with the exception of trauma cases or low-risk cases.
But we analyzed the preoperative documentation at one site and discovered that approximately 19 percent of cases logged the AST less than a minute before PIR, often mere seconds apart.
Discussions with clinicians uncovered the inconvenience of documenting the actual anesthesia start time by logging into the system in the preoperative holding area. Instead, providers simply waited until they were in the OR and clicked both the AST and PIR buttons when logging into the AIMS.
Our analysis at this site indicates that approximately 3,400 cases a year may have been eligible for an extra unit of billing, or approximately $120,000 per year in unbilled time.
Expanding the Investigation
We spoke with a handful of other sites, with a wide variety of responses — we heard everything from:
“We take a conservative approach to avoid concurrency issues.” to “It’s a huge problem we haven’t solved.” to “We worked with compliance and regulatory agencies to develop our own alert to drive a disciplined approach and it’s worked well.”
Taking the Right Approach
At AlertWatch, we believe the right approach from both a compliance and workflow perspective is to document care in real time, ideally without distracting from the task at hand. Clinical environments need to balance patient needs with documentation requirements.
When sites moved from paper (a truly “mobile” system) to modern AIMS, this discrepancy arose, as many preoperative areas are often not set up to document anesthesia start time electronically.
The problem is that not only does this lead to underbilling, but a mischaracterization of clinician involvement in continuous patient care as well.
Having a targeted alert — such as the one we recently developed for AlertWatch:OR — makes sense.
This is similar to the decision support an AIMS provides when a physician attempts to document the medical direction of more than four cases. Along the same lines, a targeted alert for documented preoperative anesthesia care that seems either too short or too long shouldn’t carry concurrency risks, if implemented correctly.
That’s why we developed the anesthesia start time alerts; they provide clinical decision support during the case, to help clinicians correct their documentation when they have a moment. We expect this will drive greater consistency in preoperative documentation across a site.
If you’re interested in reading (or forwarding) the full whitepaper text, please email us and request it.