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Documenting Relief Times for Anesthesia Providers

It may seem like a small thing, but correctly documenting  anesthesia relief time (when one provider comes into the OR to relieve another) can significantly reduce your compliance risk, while saving you and your billing office a great deal of time and energy. 

The risk:

This is a medical direction issue.  Obviously, a provider cannot be in two places at one time.  However, sometimes the documentation, or lack thereof, makes it look as though that is what has occurred.  In the event of an audit, the lack of proper documentation can put your entire practice at great risk.  At the least, significant fines can be assessed in cases of non-compliance.

The problem:

As a billing company that specializes in anesthesia, one of the most common errors we find is that providers simply forget to document the relief situation.  Whether the scenario involves the relief of the anesthesiologist, CRNA, PA, AA or SRNA the problems are the same.  The time in, name and signature, and the time out, name and signature are often left off of the anesthesia record.  In other instances, part of the information, the provider’s name perhaps, is documented, but other parts, such as the times in and out, are not. 

Poor documentation not only creates an immediate compliance risk, but also costs you and your billing company time and energy.  Most anesthesia billing companies use software to calculate case concurrency, the number of cases per provider with times that overlap.  When there is a concurrency error, all the overlapping cases are examined for relief situations.  If the relief is documented and resolves the error, the issue can be dealt with without involving the providers and the risk of non-compliance is avoided.  However, as is often the case, the relief is not documented properly, which causes the billing office to contact the provider for a resolution.  This in turn causes delays in the workflow of the billing office and disrupts the provider’s day as well. 

The Solution:

On every anesthesia record, the names of all providers involved in the case, the times in and out for each provider, and signatures, should be legibly and clearly documented.  It’s a good idea for anesthesia practices and billing offices to develop charge sheets, anesthesia records or EMRs with specific places for entering this information. 

As an example, on the charge sheet a line for relief situations which includes, provider name, time in and time out, can be filled in.  On a handwritten anesthesia record, notes regarding relief situations should make it very clear who is relieving whom.  EMRs (electronic medical records) can be built to require this information for completion of the case. 

Documenting relief times accurately can save your time and energy and significantly reduce your compliance risk.

By: Heather E. Golfos, CPC, CANPC

Coding Department Manager

On Monday, August 14, 2017

Categories: Compliance & Coding News

The information presented herein reflects general information that is current as of the date it was first published. Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.

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