Anesthesia Services and ICD-10: It's All About the Documentation

Public and private health insurers flipped the switch to the new ICD-10 diagnostic and procedure code set on Oct. 1, and healthcare providers began selecting from 155,000 different codes to describe why a patient sought care, what treatment the patient received and what services providers can bill for.

What we’re hearing from anesthesiologists and CRNAs at our sites over the first weeks and months of ICD-10 is what we suspected going in: Clinical documentation is the key to ICD-10 compliance success.

But before I explain why and what anesthesiologists and CRNAs should do about it, I’d like to reinforce why the transition to ICD-10 from ICD-9 is important for our profession. Many of us complained that ICD-9 was not set up to capture all of the important acuity details of the patients we treated. ICD-9 did not differentiate between the anesthesia services provided to low-acuity patients and high-acuity patients. It did not recognize the intensity of services provided to the sickest patients who may have come in for simple surgical procedures but whose risk factors like obesity, diabetes or hypertension made the anesthetic aspects much more complex. And because ICD-9 did not capture that information, our reimbursement did not reflect the intensity of services provided to those high-acuity patients.

Now we have a coding system that responds to that complaint, and it’s up to us to use it properly in order to get reimbursed fairly and accurately for the hard work that anesthesiologists and CRNAs provide.

So what can we do to maximize ICD-10’s potential? It’s all about the documentation. Coders select the codes to use on claims submitted for payment based on the clinical documentation in patients’ records. The accuracy of the billing codes is only as good as the accuracy of the clinical documentation, and the clinical documentation must support the codes selected.

For anesthesiologists and CRNAs, it’s about elevating their clinical documentation skills—knowing what to document, how much to document and how to document it. We’ve worked with our providers over the past two years to sharpen their clinical documentation skills in anticipation of ICD-10. We didn’t ask them to learn all the new codes, but we did ask them to sharpen their clinical pencils, thoroughly review patients’ medical records, and document supporting comorbidities to support the codes.

A critical component of accurate and robust clinical documentation by anesthesiologists and CRNAs is communication with other members of the surgical team. We recommend to our providers at our sites that they review what happened in the operating room with the surgeon and OR nurses before they exit the suite. What procedure was done? How long did it take? Were there any unanticipated procedures done? What is the post-procedure diagnosis?

In addition to greatly aiding the documentation by anesthesiologists and CRNAs, communication with other members of the surgical team also aligns the clinical documentation of anesthesia services, the surgeon and the facility where the procedure was done. The documentation of all three parties should be consistent. Discrepancies could lead to unsupported ICD-10 codes, and unsupported ICD-10 codes could lead to payment delays and denials.

Anesthesiologists and CRNAs who know what to document, who can document with precision and who can communicate effectively with other members of the surgical team will put their practices in the best position to succeed under the new ICD-10 billing system.

What ICD-10 compliance tips would you add to this list? What have you learned so far? Share them with me at [email protected]. If you need a quick refresher course on ICD-10, you can download this overview from CMS.