Documenting Anesthesia Time

Start Time:
1) Pre-OR time is scrutinized by the government because most pre-OR anesthesia services are bundled into the base units. There are only 2 types of pre-OR time that are billable, meaning your billed start time is prior to your in-room time:

• Administering sedation (or a regional anesthetic) to the patient or
• Transporting a patient from ICU where it is medically necessary for an anesthesia provider to do so.

Continuous pre-OR time is when you administer sedation and remain with patient until entering the OR. To document this time, you must document:

• The event for which you are billing and
• The time of the event by either entering the start and stop time or by entering the start time and language indicating you are continuously present with the patient.

1. Discontinuous pre-OR time occurs when a regional anesthetic is administered, and the provider leaves the patient temporarily. To document discontinuous time, you must document the event, start time and stop time.
2. In OR room time must be documented either by the OR nurse or the anesthesia provider. Medicare auditors will start your billable time from your in-room time, if it is documented. If no in-room time is documented, auditors will typically default to the next documented event which will probably be several minutes after the anesthesia start time and cause a loss of billable minutes. Medicare auditors do not simply accept anesthesia start as the start time; they must have a corroborating event which is usually the in-room time.
3. For lines and blocks, you should document the start and end times. There are instances where the time to place lines and blocks must be deducted from the total. billable time. The standard protocol, if the workflow allows, is to document the start and stop of the placement of the block or line by either indicating that time on a paper record or using the appropriate start/stop/pause/resume functions in the EMR. The biller will then determine whether the time must be deducted per the CPT code.

Stop Time:

1. The legal definition of stop time occurs "when the beneficiary may be placed safely under postoperative care." Like anesthesia start time, Medicare auditors do not accept anesthesia stop as the billable stop time without a corroborating event. That event is labeled differently at different locations and in different charts.
   It can be referred to as PACU handoff, care transfer, or something similar. The anesthesia stop time must match this event time, and both times must be documented.
2. Anesthesia providers cannot bill past the handoff/care transfer time. This time is the legal billable end time. Per outside counsel, David Vaughn, his team has audited numerous groups where their billed stop time is after the handoff time because billers/coders are only looking at the labeled anesthesia stop time. It is important that our providers strive to document anesthesia stop simultaneously with the PACU handoff/transfer of care time.