Anesthesiology Practice Pays Nearly $2 Million To Settle Improper Billing Claim

-->October 12, 2017Company News

Matthew Harrison, RHIA, CPC, CCP
Chief Compliance Officer

Judgement Against Anesthesiology Practice for Improper Billing of Time Units

Requests for additional information regarding documentation deficiencies are a burden, but they are also absolutely necessary to ensure your claims are complete and appropriate. If you perform moderate sedation, you have likely received a request from your billing firm asking for documentation of the sedation time. The recent judgement of nearly $2 million against a NY anesthesiology practice is precisely why these questions are vital to the success of your practice.

Just like anesthesia, time must be clearly documented for general, regional, and monitored anesthesia care cases. The American Medical Association, through its CPT coding guidelines, has also imposed time documentation requirements on moderate sedation. Moderate sedation is billed and reimbursed in 15 minute increments. Providers must document the “intra-service” time they are in attendance with the patient while administering moderate sedation. Note that while the codes (99151-99157) represent 15-minute increments, the code for the first 15 minutes can be billed once the intra-service time reaches a minimum of 10 minutes. Anything less than 10 minutes is not billable.    

Per CPT, Intra-Service Time:

  1. Begins with the administration of the sedating agent(s)
  2. Ends when the procedure is completed, the patient is stable for recovery status, and the physician or other qualified healthcare professional providing the sedation ends personal continuous face-to-face time with the patient
  3. Includes ordering and/or administering the initial and subsequent doses of sedating agents
  4. Requires continuous face-to-face attendance of the physician or other qualified healthcare professional
  5. Requires monitoring patient response to the sedating agents, including:
    1. Periodic assessment of the patient
    2. Further administration of agent(s) as needed to maintain sedation, and
    3. Monitoring of oxygen saturation, heart rate, and blood pressure

Note that pre-service and post-service work cannot be included in the intra-service time used to calculate the billable time period. Reimbursement for these activities are already included in the value for the code.

Pre-Service and Post-Service Activities Include:

  1. Assessment of the patient’s personal or family medical and surgical history, including previous experiences with anesthesia/sedation
  2. Review of patient’s current medication list
  3. Exam of the patient (even for anesthesia-related services such as mallampati assessment, chest/lung exam, and heart/circulation exam)
  4. Review of pre-sedation diagnostic tests
  5. Obtaining informed consent
  6. Immediate pre-sedation assessment prior to first dose of sedating agent(s)
  7. Initiation of IV access and fluids to maintain patency
  8. Assessment of vital signs, consciousness, and pulmonary stability in the post-sedation recovery period
  9. Assessment of patient’s readiness for discharge
  10. Documentation time
  11. Communication with family/caregivers

If you are billing these cases yourself, you must ensure you are following the proper coding guidelines and that your documentation supports all services billed. Even if you enlist the help of a billing service, you must ensure that they are (1) Not billing services that aren’t documented, and (2) Reviewing your documentation and providing feedback on any deficiencies that may impact your ability to bill certain services.

In this case, the company over billed more than $600,000 to Medicaid but ended up paying almost $2,000,000 making this a very costly miscalculation.

Important Note: The linked article references the “16-minute rule”. This rule is no longer valid as of 01/01/2017.  This was applicable with the old codes for dates of service prior to 1/1/2017. For dates of service 1/1/2017 and after, the new threshold is 10 minutes. Providers must provide and document a minimum of 10 minutes of intraservice time in attendance with the patient in order to bill the sedation.