Anesthesia “on standby” for high risk OB deliveries (twins)

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ISoNitrous

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Hey gang,

I’m wondering if anyones’s group or Hospital has a formalized process for an anesthesia team/provider being on “standby” if needed.

The classic scenario here is vaginal delivery of twins, which our OBs often do in the C-section room in case immediate operative intervention is needed. They request that we are on standby and can provide anesthesia if anything doesn’t go according to plan (I.e. induce for a section).

Do you run into this issue? It occupies staff for us, and regardless of not billing despite tying up resources, we are trying to find the best way we can indicate “Hey, we were here.”

Thanks for chiming in.

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Hey gang,

I’m wondering if anyones’s group or Hospital has a formalized process for an anesthesia team/provider being on “standby” if needed.

The classic scenario here is vaginal delivery of twins, which our OBs often do in the C-section room in case immediate operative intervention is needed. They request that we are on standby and can provide anesthesia if anything doesn’t go according to plan (I.e. induce for a section).

Do you run into this issue? It occupies staff for us, and regardless of not billing despite tying up resources, we are trying to find the best way we can indicate “Hey, we were here.”

Thanks for chiming in.

they deliver them in the OR. They give us a heads up that it is happening. They call us if it needs to turn into a csection. We certainly aren't having someone sit there and twiddle thumbs for however long it takes.
 
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If they request your presence in the delivery room, can’t it be charted and billed as a MAC?
 
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If they request your presence in the delivery room, can’t it be charted and billed as a MAC?
If they ask us to physically be in the room, then I always chart as a Mac case. CMS doesn't require that any medication be given, just that you are monitoring.
 
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To answer the question, our practice shows up when requested as I think it's hard to defend not showing up if there's real concern/risk for a c-section. We have one OB who also worries a lot about shoulder distocia (sp?) and will ask us to be around but that one I fight a little harder.

As far as billing
-If no epidural it's basically billed as an "anesthesia for vaginal delivery" which is basically starting a chart and MAC is the anesthetic.
-If epidural is in place I dont think much changes it's just that you're present for the delivery. You can change the billing if you chart a MAC, but that involves closing the labor chart and starting a new chart "i believe". I typically will do this if the twin delivery isn't "fast". If it's something where they need me there for a few pushes then I just continue the regular labor epidural chart.

Edit: The new chart will increase your units so that's why if I'm in there say longer than 20 minutes, I will start a new chart. 2 units / hour vs 4 units / hour
 
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How much do they pay an hour on standby? ASC land we do not have standby. They should pay at least 250-300 an hour for standby active what ever.
 
Where I trained, they made us (residents) sit in the OR for the delivery. I think we did monitor, so charged for MAC.
Where I am now, we get a heads up that they're delivering in the OR, but we're not in the room unless things go south and we're needed for a section. We are in house 24/7 when covering OB.
 
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To answer the question, our practice shows up when requested as I think it's hard to defend not showing up if there's real concern/risk for a c-section. We have one OB who also worries a lot about shoulder distocia (sp?) and will ask us to be around but that one I fight a little harder.

As far as billing
-If no epidural it's basically billed as an "anesthesia for vaginal delivery" which is basically starting a chart and MAC is the anesthetic.
-If epidural is in place I dont think much changes it's just that you're present for the delivery. You can change the billing if you chart a MAC, but that involves closing the labor chart and starting a new chart "i believe". I typically will do this if the twin delivery isn't "fast". If it's something where they need me there for a few pushes then I just continue the regular labor epidural chart.

Edit: The new chart will increase your units so that's why if I'm in there say longer than 20 minutes, I will start a new chart. 2 units / hour vs 4 units / hour

i thought you cant double bill like that for a delivery?
 
i thought you cant double bill like that for a delivery?
That's not double billing. Once you're in the OR, it basically becomes an OR case, you just need to properly document. As said above, "give a touch of something" to make it legit. Immediately present gets you 4 units, similar to the insertion time, which is why some people always take 48 minutes to place epidurals lol. I've been told so long as you document you were there and doing vitals you can get 4 units for any top offs you do. I don't do it because I don't want anyone digging through my charts, but I think techically it's legit because you are present in the room, giving a drug, and monitoring the patient.
 
That's not double billing. Once you're in the OR, it basically becomes an OR case, you just need to properly document. As said above, "give a touch of something" to make it legit. Immediately present gets you 4 units, similar to the insertion time, which is why some people always take 48 minutes to place epidurals lol. I've been told so long as you document you were there and doing vitals you can get 4 units for any top offs you do. I don't do it because I don't want anyone digging through my charts, but I think techically it's legit because you are present in the room, giving a drug, and monitoring the patient.

maybe its different here. i was told if patient has epidural then goes to OR for section, it cant be 2 records because that be fraudulent billing
sometimes due to IT issues or by accident, a 2nd record is made for C section, then we will get emails about combining the 2 records (labor, and C section) to 1
There is a button on our Epic EHR that says "Epidural to C section". we have to click that to combine the 2 records.
 
maybe its different here. i was told if patient has epidural then goes to OR for section, it cant be 2 records because that be fraudulent billing
sometimes due to IT issues or by accident, a 2nd record is made for C section, then we will get emails about combining the 2 records (labor, and C section) to 1
There is a button on our Epic EHR that says "Epidural to C section". we have to click that to combine the 2 records.
That's how our place is set up here and I'm in midwest
 
maybe its different here. i was told if patient has epidural then goes to OR for section, it cant be 2 records because that be fraudulent billing
sometimes due to IT issues or by accident, a 2nd record is made for C section, then we will get emails about combining the 2 records (labor, and C section) to 1
There is a button on our Epic EHR that says "Epidural to C section". we have to click that to combine the 2 records.

you can't concurrently bill the epidural and the anesthesia time in the OR, but you can bill the OR time instead of the epidural at that point because you are literally providing MAC even if you do nothing but sit and chart vitals
 
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maybe its different here. i was told if patient has epidural then goes to OR for section, it cant be 2 records because that be fraudulent billing
sometimes due to IT issues or by accident, a 2nd record is made for C section, then we will get emails about combining the 2 records (labor, and C section) to 1
There is a button on our Epic EHR that says "Epidural to C section". we have to click that to combine the 2 records.
C-section after labor is a separate code......01968. If you do a vaginal delivery in OR without any epidural it's 01960. If they have an epidural and you go to the OR for a delivery it's still 01967 but you have to document your presence, and I believe, because you're present you can bill 4 units/hr similar to insertion time. All this just requires a lot of documenting and charting which like I said, if it's for a 20 minute push it's not worth it but if you're in there with them for an hour that's a different story.
 
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you can't concurrently bill the epidural and the anesthesia time in the OR, but you can bill the OR time instead of the epidural at that point because you are literally providing MAC even if you do nothing but sit and chart vitals
Yep. This. It's your presence that changes things. That's why insertion time is billed at 4/hr because you're there and charting.......as I said, some people take 48 minutes to place ALL their blocks. Not me, but some lol
 
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For twins we are notified and they deliver in the OR. Not required to be present but typically the on call CRNA will hang around if nothing else is going on.

I do encourage epidurals in these patients. Lots of big ladies in the south so I prefer to avoid general if possible when baby B decides to flip.
 
Yep. This. It's your presence that changes things. That's why insertion time is billed at 4/hr because you're there and charting.......as I said, some people take 48 minutes to place ALL their blocks. Not me, but some lol
this may be different but for post op blocks for ortho cases, we do them in the OR. we were told we are supposed to bill time after post op block to start the x unit/hr because the time for the post op block cant count.. i guess procedures time for main anesthetic time is different?
 
this may be different but for post op blocks for ortho cases, we do them in the OR. we were told we are supposed to bill time after post op block to start the x unit/hr because the time for the post op block cant count.. i guess procedures time for main anesthetic time is different?

You carve out time for the block

In room at 901
Monitors on
+/- sedation
Block start 907 End 908
Restart anesthesia time 909
Monitor until 949
48 minutes minus 2 for the block

If I'm there even if I don't push meds I bill for the time
 
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this may be different but for post op blocks for ortho cases, we do them in the OR. we were told we are supposed to bill time after post op block to start the x unit/hr because the time for the post op block cant count.. i guess procedures time for main anesthetic time is different?
The reality is that anytime you're in the presence of a patient being an anesthesiologist and charting vitals, you can bill anesthesia time. Anything. Otherwise, why are you there? Nothing in this world is free
 
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We do ours in the delivery suite, which is adjacent to theatres. I believe we bill for MAC, but I haven't done one except as a resident
 
maybe its different here. i was told if patient has epidural then goes to OR for section, it cant be 2 records because that be fraudulent billing
sometimes due to IT issues or by accident, a 2nd record is made for C section, then we will get emails about combining the 2 records (labor, and C section) to 1
There is a button on our Epic EHR that says "Epidural to C section". we have to click that to combine the 2 records.
You're billers are clueless. Of course it's a different record - it's a different anesthetic.

Your first record/bill is for placement of the epidural and whatever monitoring is done (flat fee, X units/hr, whatever).

Once it becomes a C-Section, your laboring epidural time ends at 00:00 and your C-Section procedure time begins at 00:01. Totally separate record and billing because they are two separate procedures. I guess they could be combined on one record - but they're still separate and distinct and should be treated that way from a billing standpoint. If your billers are billing all this as a single anesthetic, you're not only leaving money on the table, but that potentially makes the entire encounter from labor epidural placement to end C-Section time a single anesthetic. That's problematic from both a billing and medical direction standpoint.

This is no different than what we do in the OR. Our pain blocks are almost all done in pre-op. A pain block done for post-op pain only is charged as a procedure, with no time component, and, if doing medical direction, without an anesthetist presence since doing blocks is one of the allowable exceptions under TEFRA. Then when that patient goes to the OR, it's the usual anesthesia charges (base + time + modifiers) like any other case. If the pain block is the primary anesthetic for the procedure (like an ISB plus GA or MAC), you can bill for time, but not the block. If you do it this way and medically direct, then your anesthetist needs to be present, because that's part of the overall procedure and it counts as one of the four cases you're medically directing.
 
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