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5 Lessons to Anesthesia Billing

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Vital Signs for Healthy Anesthesia Practices: a Checkup


PPMIS Vital Signs

The job of keeping your practice financially healthy and independent is a constant struggle, and we are striving to provide anesthesiologists and practice managers with timely information and tools to do your jobs well. The regulations and rules changed dramatically with the Patient Protection and Affordability Care Act of 2010, and with the rules for Accountable Care Organizations that were just released on March 31st (

The American Society of Anesthesiology will likely comment during the allowed 60 day period very soon ( How anesthesiology providers interact, work within, and are reimbursed by ACOs will be determined by these rules when they are set. In the meantime, surgical schedules will fill up, patients will be seen and treated, and your practice will need to function as optimally as possible given the uncertainties of today. Sound financial decisions and excellent revenue cycle management will be key elements to success. Anesthesiology practices will also need to monitor the following areas of performance. These areas to watch include;

  • Is your practice ready for the ANSI 5010 changes?
  • Are you viewing and resolving your electronic claim rejections?
  • Are you performing charge capture reviews?
  • Is your insurance and demographics information "clean"?
  • Are your payor denials being worked. Appeals being submitted? Requested information being delivered?

For more practice tips and important financial factors of anesthesia billing, subscribe to our upcoming newsletter called "Vital Signs." The first issue will focus upon the Accountable Care Organization rules, and what they might mean to anesthesiology providers.  

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6 Ways to Maintain Patient Relations and Still Get Paid


Maintain Patient RelationshipsWith today’s economy and high unemployment rates, many patients are struggling just to make day to day ends meet, not to mention those who have health issues. When a medical emergency arises, patients often rank payments for these services lower on their priority list.

As a medical provider, you strive to meet the needs of your patients while maintaining a successful practice. With the cost of healthcare services rising, many medical providers are experiencing a higher percentage of patients unable to pay. That’s why it is vital for today’s medical practice to establish strict payment policies for sustaining your livelihood.

Strict financial policies not only set the expectations for your patients, but also help your staff follow operational processes based on the rules you establish for monitoring and collecting money owed.

Consistency is essential to successful collections.

  • Establish strict collection policy.
  • Monitor A/R account regularly.
  • Take action when an account is 30 days past due.

It becomes more difficult to collect on outstanding debt when an account is past due 90 days to 120 days.

Communication is key to maintaining patient relations.

Most misunderstandings come from the patient not knowing how his or her insurance coverage works and what his or her financial obligations are to you.

  1. Explain the patient’s financial responsibility. Make certain that your staff has done its homework prior to the patient’s appointment.
    • Verify insurance coverage and contract information.
    • Update the patient demographics.
  2. Discuss insurance coverage with the patient. Make certain the patient understands how his or her insurance coverage works. If you do not have the time, suggest that the patient contacts the payer directly to confirm coverage.
  3. Discuss that occasionally the financial obligation may change as in surgical cases. Make certain the patient is made aware that if complications arise, the billable amount may exceed the estimated cost.
  4. Offer a prompt-pay discount. Work with your physicians to offer an incentive for patients who can pre-pay or pay the full amount within 30 days.
  5. Establish payment plans for patients who cannot pay the full amount within 30 days. You can manage the payment plan in your office or contract with a third-party company to manage all of your payment plans.
  6. Follow up by phone for money owed. Establish collection methods to ensure your staff stays on top of outstanding debt. Have a firm policy in place for following up.

To learn more about medical billing, download our Free 8 Lessons to Medical Billing.

Download 8 Lessons to Medical Billing

Rules for Accountable Care Organizations (ACOs)


Rules for ACOsLast Thursday the rules for ACOs were shared by CMS after many weeks of delay. The 427 pages of proposed rules that were released trigger a 60 day comment period back to CMS.

Many specialists including anesthesiology have concerns that the ACO model and its web of new regulations pose financial risks for providers. Although the intent of the formation of ACOs may be the unification of mutiple healthcare providers around quality patient care delivery, the question of how the ACOs will truly function in the market remains unanswered. Pilot ACOs are up and running around the country to prove the concept. 

Anesthesiologists will need to know how their participation in a local ACO will affect their practices. The American Society of Anesthesiologists (ASA) has an ACO Taskforce that will be evaluating the impact of these rules on the profession. You can look for their response to the new rules under News and Events on the ASA Web site at in the coming days.

PPMIS will examine the proposed new rules in great depth in our upcoming newsletter called Vital Signs. To sign up for this e-newsletter, subscribe now.

Vital Signs will be sent to you soon.

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Is pain management a viable choice?


Anesthesia Pain ManagementPain management has existed for approximately 30 years. Anesthesiologists long have been part of the forerunners of medicine. From the beginning, credentialing was critical to the existence and promotion of the specialty. The American College of Pain Medicine and the American Board of Pain Medicine were developed to serve as the legitimate credentialing bodies for pain clinicians in the US. In United States, the American Board of Medical Specialties (ABMS) is the gold standard for credentialing of medical specialties.

Significant leaps have been made in implementing new pain therapies, effectively treating more patients, and understanding pain mechanisms. There are still many obstacles to perambulate in order for pain management to reach its maximum potential.

Pain Mechanisms and Pain Pathophysiology

Basic science has been exceptional in putting out quality scientific findings regarding pain mechanisms and pain pathophysiology. There needs to be a move in making this information more clinically relevant and useful to an acting physician at the patient’s bedside. The trend in relational research should be advanced at the university level in which interaction between basic scientists and pain clinicians should unfold and be nurtured to provide clinically relevant innovations, techniques, and therapies that will benefit the chronic pain patient.

There are relatively few well-developed placebo controlled studies dealing with pain-related therapies. This situation exists because it is difficult to implement in a typical pain clinic setting. Issues like pain measurement and pain assessment are still quite primitive and can be difficult to measure.

The visual analog scale (VAS), despite its short comings, remains the gold standard of pain assessment. With refocused efforts, this situation should change and reliable objective measures should come forth; a joint effort would be required between a basic scientist, pain clinician, government, and industry. The role of industry is diminishing for a multitude of reasons including economics.

Pain Management as a Discipline

Acute pain management is a discipline usually given high cheer by surgical patients in hospitals. They state in hospital surveys that outstanding pain management administered by the acute pain service is the highlight of their stay. Reimbursement for these services is far from satisfactory. To provide this essential service to patients that can afford it least, methods need to be developed to aid departments, providing important acute pain service the same way an emergency service does in a hospital.

The relationship between anesthesiologists and nurse-anesthetists (CRNAs, or nurses) is improving, and in many medical centers, residents and CRNAs work in conjunction, some under the supervision of attending or consultant anesthesiologists – some may work in an opt-out state. Related article Anesthesia Providers – What They Do and Who They Are.

Attempts to enhance strategies for anesthesia training and education are being implemented to increase knowledge, also as a tool to encourage anesthesia trainees to remain in academic centers as junior faculty after training. This approach is imperative, since the professors of anesthesia of tomorrow will come from the current group of trainees. The future of this group is dependent on the level of education they receive.

Programs are being conceived to allow residents coming in to blend research projects into their anesthesia training programs so that early on, academic incentive is a part of their career. Scholarly programs like these will refine the education base on which the future of anesthesiology will continue to advance.

The Basica to Anesthesia Billing

Breaking Down the Medical Billing Process


Medical billing is the process of billing patients and insurance companies for services rendered by a healthcare provider.

The medical billing process requires communication between the healthcare provider and the insurance company (often called the payer). This communication begins with the office visit and continues through the billing and collections process.

The payer is typically the first point of contact in the medical billing process unless the patient does not have healthcare insurance. In this case, the patient is solely responsible for paying for all services rendered.

The medical billing workflow is the same regardless of the size of the medical billing office. In larger offices, duties are assigned by job functions and are performed by many individuals. In smaller offices, one individual may perform all duties.

Medical Billing Process

The Medical Billing Process by Role

The role of the Billing Specialist is vital to the financial operation of the practice or the billing service. The responsibilities of the billing specialist vary by practice and billing service and can include both specialists and clerical responsibilities. The responsibilities of this role include the following:

  • Helps individuals, patients, or clients submit medical bills to the insurance company.
  • Communicates with medical office and insurance company on behalf of the client.
  • Explains insurance company documents to the client or patient.

The following is a description of the medical billing process from the patient encounter to reimbursement of the claim:

Roles and Responsibilities of Medical Billing Specialists

To learn more about medical billing, download a free copy of 8 Lessons to Medical Billing.

Download 8 Lessons to Medical Billing

7 Habits of Highly Effective Practice Managers


The successful medical practice managers of 2011 have to have a growing list of skills and attributes to bring to the job. Practice ManagerThese skills probably include leader, staffing specialist, financial wizard, negotiator, medical billing expert, IT and software guru, communicator, and occasionally crisis manager. In the narrower context of an anesthesia practice, these skills must be ramped up to even a higher level. Anesthesia providers already have a low margin for error. Like airline pilots, zero defects are an expectation and the norm.

So, what are the habits that the best of the best work to attain? The top seven might include:

  1. You staff the operation with team players who know and work toward the goals set by you and your physicians.
  2. You are always “in the hunt” for new tools and efficiencies for the practice workflow.
  3. You continuously monitor the financial health of the practice using up-to-date tools, such as custom dashboards. The current financial status of your practice is only a few clicks away.
  4. You anticipate versus react to situations, with clear contingency planning for unforeseen problems and issues.
  5. Your clinicians support you, know your goals, and continue a good two-way dialog.
  6. You make time to “sharpen the saw” by going to key meetings and seminars to improve your perspective and skill sets.
  7. Your practice software and IT equipment is optimized to maintain practice performance, with the effective use of electronic dashboards and robust reporting.

These habits and skills are the core of a successful medical practice. To get the basics ingrained as habits, peruse our 8 Lessons to Medical Billing.

8 Lessons to Medical Billing

Billing and Coding - the Experts Point of View


The medical coder’s role is extremely important in the medical billing process. Using the expertise of a certified medical coder ensures your claims are paid on the first submission, resulting in faster reimbursement.

Medical coders believe that every picture tells a story. The medical coder is challenged with telling the story that has been told to them by the services that a patient received, but with numbers and not with words.  

Typically, medical coders receive either a Superbill or a Charge Ticket (or an alternate means of relaying the information) from the provider and from this, the claim begins the birth process.

It is important to understand that the method of relaying this information to the coding/billing team is almost never a legal document. It is simply a summary of what transpired. The story is based upon legal documents such as the anesthesia record, the operative record, the intra-operative nursing record, etc.

The key thing to keep in mind is that the insurance carriers never see the Superbill or the actual Charge Ticket. When the medical coder receives the Superbill or Charge Ticket, the verbiage must be converted to a series of codes.

How a Master Coder Might Handle a Case

Master CoderDr. Alpha, an anesthesiologist, sends the billing office an anesthesia ticket for a patient who has coronary artery disease and for which the patient underwent anesthesia for a 4-vessel coronary artery bypass graft (venous). The procedure was done with the use of bypass and cardioplegia. The anesthesiologist also placed an arterial line in the right radial artery and a Swan Ganz catheter for monitoring purposes.

While it is clear to the medical coder what was done, the insurance carrier needs to know what was done but cannot receive the verbiage as stated above. The medical coder is challenged with the task of converting the events into codes that will tell the same story.

The Deciphering Process Begins

From the paperwork received, the medical coder assigns CPT-4 code 33513 (Coronary artery bypass, vein only; 4 coronary venous grafts), ASA code 00567 (Anesthesia for direct coronary artery bypass grafting; with pump oxygenator), 36620 (Arterial catheterization or cannulation for sampling, monitoring or transfusion; percutaneous), and 93503 (Insertion and placement of flow directed catheter [Swan-Ganz] for monitoring purposes).

The case is coded with the ICD-9 (diagnosis) code of 414.00 (Coronary atherosclerosis of unspecified type of vessel, native or graft). Of course, if the anesthesiologist has more detailed information or if the operative record yields a more definitive description, the ICD-9 code can be tapered to describe such.

The coding sequence would be as follows:



If the anesthesiologist tracks PQRI and the patient has Medicare, appropriate antibiotic order/administration as well as full barrier protection may be assigned utilizing 4047F, 4048F, and 6030F.

The case is then given to the billing specialist for data entry from which the claim is submitted.

For additional information about the role of the medical coder, read Why is a medical coder important to medical billing?

Download a free copy of 5 Lessons to Anesthesia Billing.

Download 5 Lessons to Anesthesia Billing

Why is a professional medical coder important to medical billing?

Medical Billing & Medical Coding ImageUsing the expertise of a certified medical coder ensures your claims are paid on the first submission, resulting in faster reimbursement.

The primary responsibilities of the medical biller and medical coder are billing for the services rendered by a healthcare provider. While these disciplines are highly dependant on each other, their job functions are very different.

  • The primary responsibility of the medical biller is making sure the healthcare providers get paid for their services.
  • The primary responsibility of the medical coder is coding claims accurately for submission to insurance payers.

The U.S. Department of Labor predicts growth of more than 20% in the field between 2008 and 2018 (the last estimates available). This means over 35,000 new medical billing and coding jobs will be created.

The Role of the Medical Coder
Medical coders are specialists who interpret medical reports written by physicians and other healthcare providers into simple medical and descriptive terms for billing purposes. It’s imperative that the medical coder interprets the medical report accurately to ensure the insurance payers understand the claim so that it won’t be rejected.

Some medical coders specialize in coding anesthesia, cardiology, interventional, emergency, hospital, or physician based claims. According to American Academy of Professional Coders (AAPC), the requirements of a medical coder are:

  • Proficiency in adjudicating claims for accurate medical coding for diagnoses, procedures and services in physician-based settings
  • Proficiency across a wide range of services, which include evaluation and management, anesthesia, surgical services, radiology, pathology and medicine
  • Sound knowledge of medical coding rules and regulations including compliance and reimbursement. A trained medical coding professional can better handle issues such as medical necessity, claims denials, bundling issues and charge capture
  • Knowing how to integrate medical coding and reimbursement rule changes into a practice's reimbursement processes
  • Knowledge of anatomy, physiology and medical terminology necessary to correctly code provider diagnosis and services

The medical coder uses a system of alpha numeric codes used either nationally or internationally in the health profession to designate various aspects of the medical process, which includes:

  • Checking a variety of sources within the patient’s medical record, including the transcription of the physician’s notes, ordered laboratory tests, requested imaging studies and other sources, to verify the work that was performed.
  • Having a thorough knowledge of anatomy and medical terminology is essential. It is also important that the medical coder is familiar with different types of insurance plans, regulations and, of course, CPT®, HCPCS Level II and ICD-9-CM codes and guidelines. This knowledge enables the medical coder to assign correct codes and service levels for the procedures performed and supplies used to treat the patient and to properly identify the physician’s diagnoses.

Diagnostic and Procedural Codes

Diagnostic and Procedure Codes

Medical coders tells the story that has been told to them through the patient medical record, but with numbers and not with words. Read more...What Would a Master Coder Do?

RCM ServicesPPMIS offers a full-service medical billing service that provides multi-specialty billing, certified coding, SaaS technology, demographic and EMR downloads, payer credentialing, and practice advocacy.

Who Is the Anesthesia Care Team?


The Anesthesia Care Team (ACT) is primarily made up of an anesthesiologist and either a Anesthesiologist Assistant or Nurse Anesthetist. ACT is responsible for keeping the patient anesthetized during surgery, which includes monitoring the patient’s vital signs, for example, heart rate, blood pressure, body temperature, and breathing, while the patient is under anesthesia or sedation.

Anesthesia Care TeamThe Anesthesiologist Assistant (AA) and Nurse Anesthetist (NA) have the same responsibilities. Both are integral members of the Anesthesia Care Team and function as anesthetists led by a qualified anesthesiologist.

Anesthesiologist Assistant
Anesthesiologist assistants are physician assistant specialists in control of acute pain, chronic pain and are involved in the care of critically ill patients. The Boards of Medicine and Osteopathic Medicine approved the first Anesthesiologist Assistant license in Florida at their recent meeting, held March 31, 2005. The 2004 Legislature passed senate bill 626 and was signed by Governor Bush in June 2004. The bill creates the licensing of Anesthesiologist Assistants in Florida. Florida is considered a key state in regards to the licensing of Anesthesiologist Assistants throughout the country. Due to this recent approval from the boards of Medicine and Osteopathic Medicine the doors are now open for the remaining states to follow suit.

In the United States, an anesthesiologist assistant must complete two and a half years of training in a CAAHEP accredited anesthesiologist assistant program after obtaining a baccalaureate degree and required medical prerequisites.

The National Commission for Certification of Anesthesiologist Assistants (NCCAA), which was founded in 1989, provides the certification process for AAs in the United States. The Commission includes anesthesiologists and anesthesiologist assistants. NCCAA contracts with the National Board of Medical Examiners to assist with the certification process, including task analyses, development of content grids, item writing and editing, and administration of examinations. The certification process incorporates a 6-year cycle of certifying examination, examination for continued demonstration of qualifications, and registration of continuing medical education.

Nurse Anesthetist
A nurse anesthetist, also known as a Certified Registered Nurse Anesthetist (CRNA), is an advanced practice registered nurse whose additional educational training specializes in administering anesthesia. The CRNA performs similar duties as the anesthesiologist. Most CRNAs work in conjunction with anesthesiologists. The CRNA’s responsibilities are largely related to operative procedures.

CRNAs usually practice as individuals or in a group practice in hospitals (for example, surgical suites or obstetrical delivery rooms), outpatient surgery facilities, and dental, ophthalmology, podiatry, or plastic surgery offices. Military mobile care units or veterans hospitals often use CRNAs as the chief anesthesia providers. CRNAs may also work in the areas of research, quality assurance, critical care management or oversight, and administrative roles.

Currently there are 16 states in the U.S. where CRNAs are granted the right to independent practice without physician supervision. The needs for available, safe, and effective care ensure the ongoing need for CRNAs in the healthcare environment especially in remote centers and rural populations where anesthesiologists are scarce. Read more...What Does Opt-Out Mean to the Anesthesia Community

The nurse anesthetist must first have a bachelor's degree in registered nursing. Nurse anesthetist training is provided by both hospitals and universities, and a master's degree is awarded after completing 24-36 months course work and at least 800 hours of clinical experience. Nurse anesthetists must also pass a national certification examination before they are allowed to practice. CRNAs must be recertified every two years and that requires continuing education credits specific to the specialty as well as proof of a designated number of hours spent giving anesthesia to patients.

Beginning in the 1800s, nurses were first among professionals to administer anesthesia in the United States. The nurse anesthetist is recognized as the first clinical nursing specialty. Nurse anesthetist came about in part because doctors were needing to resolve the high mortality rate due to anesthesia. This need allowed nurses to monitor patients and allowed doctors to focus on their procedure. Being pioneers in anesthesia, nurses helped continue refining the provisions of anesthesia. Read more...Nurse Anesthetist History

Billing for anesthesia services is a challenge for every anesthesia provider. Submitting clean claims the first time is vital to the anesthesia practice. PPMIS, a leader in anesthesia billing software and services, can help eliminate the frustration of submitting and resubmitting claims.

If you’re interested in knowing how, get connected...

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Are Anesthesiologist Assistants and Nurse Anesthetists the Same?

The Anesthesiologist Assistant (AA) and Nurse Anesthetist (NA) have the same responsibilities. Both are integral members of the Anesthesia Care Team and function as anesthetists led by a qualified anesthesiologist.

AAs and CRNAsWhat are the similarities?
The role of the Anesthesiologist Assistant is comparable to the NA. The NA is governed by the Nursing board, and the Anesthesiologist Assistant is governed by the boards of Medicine and Osteopathic Medicine.

The following is a list of the functions that both perform:
  • Monitor the patient's heart rate, blood pressure, breathing, and level of consciousness and analgesia. Both adjusts the anesthetic plan, fluids, medications, and other parameters to provide a safe, pain free surgical experience for the patient.
  • Take care of patient medical needs during the operation so the surgeon can concentrate on the surgery.
  • After the surgery, the AA or CRNA continues to provide the care necessary to ensure a smooth emergence from the anesthetic and pain control after your surgery.
What are the differences between AAs and NAs?
The following describe the main differences between the AA and the NA.

Prerequisites to training: Nurse Anesthetist (NA) schools require an RN degree and one year of critical care work experience. Anesthesiologist Assistant (AA) schools require an undergraduate degree emphasizing the requirements for medical school admission. American Society of Anesthesiology (ASA) agrees with the impartial findings of the Kentucky Legislature that the requirement for clinical experience may constitute a temporary aid to those beginning their NA or AA education, but it makes no difference to the final outcome of that training.

Performance of regional anesthesia and invasive catheters: Some anesthesiologists believe that neither AAs nor NAs should perform these invasive procedures. This opinion has influenced some AA programs to limit the teaching of regional techniques. That limitation is voluntary, consistent with ASA policy and was implemented to enhance patient safety.
  • More NA education programs provide instruction in the technical aspects of regional anesthesia.
  • A higher percentage of AA programs provide instruction in the placement of invasive monitors.

Supervision and independent practice: AAs must be supervised by an anesthesiologist, and NAs may be supervised by any physician. Requiring that anesthesiologists supervise AAs in no way constitutes a mark of inferiority. History has everything to do with these differences. Beginning in the 1800s, nurses were first among professionals to administer anesthesia in the United States. In some states of the U.S., NAs are granted the right to independent practice without physician supervision.

Billing for anesthesia services is a challenge for every anesthesia provider. Submitting clean claims the first time is vital to the anesthesia practice. PPMIS, a leader in anesthesia billing software and services, can help eliminate the frustration of submitting and resubmitting claims.

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