Expert Tips on Anesthesia Coding

In our latest episode of Compliance Conversations, we had the pleasure of speaking with Kimberly Jolivette Williams, a certified expert in medical coding and auditing. Hosted by CJ Wolf, this episode dives into the unique challenges and nuances of anesthesia coding and billing. Here’s a recap of the key insights and highlights from our conversation. 

Meet Kimberly Jolivette Williams 

Kimberly’s journey in the healthcare industry is both inspiring and instructive. Starting as a unit secretary in a hospital, she climbed the ranks to become a renowned compliance professional. Her dedication to lifelong learning and her passion for compliance are evident as she shares her experiences and expertise. 

The Unique World of Anesthesia Coding 

Anesthesia coding is distinct from other specialties, with its own set of rules and guidelines. Kimberly explains that the codes for anesthesia start with 00 and require an understanding of both the ASA CROSSWALK and the Relative Value Guide (RVG). Unlike other specialties, anesthesia coding involves billing based on the highest procedure performed and the base units. 

Importance of Modifiers 

Modifiers play a crucial role in anesthesia coding, indicating who performed the service—whether it was an anesthesiologist, a certified registered nurse anesthetist (CRNA), or a certified anesthesiology assistant (CAA). Kimberly emphasizes the importance of accurate documentation to avoid compliance risks and ensure correct billing. 

Resources for Learning 

For those new to anesthesia coding, Kimberly recommends starting with authoritative sources like the Centers for Medicare & Medicaid Services (CMS) and the American Society of Anesthesiologists (ASA). These resources provide valuable guidelines and updates essential for staying compliant and informed. 

Practical Tips and Advice 

Kimberly’s practical advice is invaluable for coders and compliance professionals. She highlights the importance of understanding the fundamentals of anesthesia services, the significance of accurate time documentation, and the need to create internal policies to manage risk. 

Staying Updated 

In the ever-evolving field of healthcare, staying updated with the latest changes is crucial. Kimberly shares a recent update: certified anesthesia assistants are now authorized to practice in Washington state, effective June 2024. This highlights the importance of regularly checking resources like the ASA and CMS for new developments. 

Episode Transcript

CJ: Welcome everybody to another episode of Compliance Conversations. I am CJ Wolf with Healthicity. And today we have a wonderful topic for you on anesthesia coding and billing and all things that is kind of unique. That's a whole unique area. So, we have an expert, Kimberly Jolivette Williams is with us today. Welcome, Kimberly! 

Kimberly: Hey! Hello, everybody! How are y'all doing? It is an honor to serve and be here. Thank you for having me.  

CJ: Absolutely! And thank you for making the time and being willing to share some of your expertise, Kimberly, before we get started, we love to kind. Here a minute or so from our guests about, you know, because we all end up where we are, especially in coding and compliance from different backgrounds that so we always like to hear, you know where your journey has brought you, you know where what your journey was and if you don't mind sharing a little bit about yourself before we jump into our topic.  

Kimberly: Absolutely! Well, I am Kimberly Jolivette Williams and I always tell everybody I am a raging caging Leo, right? I was born and raised in Opelousas, LA, and I had the privilege of turning 50 on July 30th of last year.  

CJ: Wow, nice.  

Kimberly: Yes, yes! So, I am in the 50 club now.  

CJ: Congratulations! 

Kimberly: And I tell you, my journey has been one of humble beginning. I literally started at the unit secretary floor in a hospital and that's I've got the training to be a unit secretary at Opelousas General High School in my little hometown where I'm from. And then I was able to move to Dallas with my mom and my sisters and my son, my son was 10 months when I moved to the Dallas, TX area from Louisiana and he will be 33 on April 13th.  

CJ: Whoa!  

Kimberly: Most people say, "Hey, you're a Texan, you've been here longer," and I'm like, "No, I won't turn loose my Louisiana roots," right?  

CJ: Yes! Fair enough. 

Kimberly: And my journey, I will tell you, I've had remarkable people to believe in me and invest in me. And that's how I kind of got into the billing and coding arena. Someone saw something in me put me in this got me in the unit secretary program. I've done check-in, check out billing and all the way up to abstract coding. I was able to get certified as a coder because the Group of physicians that I was working for as a supervisor manager, we got into a awful lawsuit. We ran an awful lawsuit for two years from 2012 to 2014. And they said, "Hey, you know what? It would be good for you and us to make sure we have the right teaching. We know the regulatories, if you're willing to do the work and become a medical certified coder and auditor, we'll pay for it 100%." And I was like; "What?"  

All my years I've been wanting to be certified and couldn't afford it, right? cause I was a single mom before I met my wonderful husband and I had to take them up on that offer. And I did the work. I became certified and the rest is history. It's like through my career.  

Here I've always had people to champion me to be able to network, my local chapters and find different people and so fast forward, I connected with one of the officers that was in my local chapter and she literally got me the job with the company I work for now, which is a very large hospital system here in the Dallas Fort Worth, Texas area and I was abstract coder and cardiovascular under her for years. Prior to that I did OBGYN for eight years as an abstract coder and a insurance department manager. And then now I had the privilege and COVID in November of 2020, someone that I worked with at the large hospital system here saw the opening and she was like, you would be perfect for this opportunity. So I was like, "Hey, I don't know. I'll apply." And lo and behold, I got it. 

CJ: Awesome!  

Kimberly: So now I am in the compliance arena since November of 2020. And I tell you, I have a thing about me, CJ. I believe if you're going to educate, if you're going to share, especially if it's with providers and staff, I think you should be certified. I mean, and that's just the Kimberly ISM of mine. And so, I took the privilege of taking the APCCPCO certification exam. The very last Saturday of the year before they closed out through an in-person exams on December 30th and I passed. So now I have my CPCO and I am in the compliance arena, currently working on the one that you have. I admire you too. I see you have the CHC. I am working toward getting that one. That should be my next credential as well, cause several of my colleagues have that. But yeah, that's just, you know, a a journey about me.  

I'm very community oriented, so I do a lot in my community. I am the local chapter president of my AAPPC, Richardson, TX chapter. I also serve on the billing Advisory Board for AAPC and work with them on their curriculum for developing questions for the certification exams. I've had the honor of writing questions for the evaluation and management curriculum previously. And I also do a lot of meet work with them, and I'm an educator, adjunct instructor for their instructor lead virtual training program, and I do the same thing for Lone Star College out of Houston, TX. I teach their medical billing and coding program.  

In my spare time, I'm very involved in my church. I serve on the praise team and the media team. I have grandchildren that take up all the time they can in my life. I have a 7-year-old granddaughter and I have a grandson too. And so I love my grandkids. My son and my daughter always say; "You do so much more and let them do so much that you didn't let us do." And I'm like, "Hey, that's part of being a chichi, right?  

CJ: Well, when do you? When do you get to sleep and take a breath? I mean, you are so busy. That's exciting.  

Kimberly: I know, right? Hey, I do try to get it in. I'm telling you, I do try to get my sleep in. And I do take a breath because, you know, I shared with you earlier. I have my mom. It's a joy, I think, to be able to take care of my mom. It could be challenging and hard because she suffers with Alzheimer's and frontotemporal dementia. And she lives with me and my husband and I have her here daily. But you know, I just take it one day at a time. I feel like I'm blessed in all of my areas, even on the hard days, you know, cause there are hard days. And there are times when I'm like, "Oh, I need more sleep."  

CJ: Exactly! 

Kimberly: But, you know, I just consider it all of joy. I consider it all a blessing. I am married to the love of my life, my best friend, my Joy. We've been married 26 years. On September 26 of this. This year, so you know, I just, I take it one day at a time. I trust in God. I know, you know he's going to see me through. He they tell you he don't give you one you can bear, right? Sometimes it feels like it, but there's always a light. So, I just focus on the light.  

CJ: Understand. Yeah, well. Thank you for sharing that and I appreciate you bringing up kind of the moments in your career where you've had a mentor. I think we've all had those types of folks and that might make a good topic in the future, but today we're going to talk about anesthesia. And I know you're an expert there. Tell us a little bit about, you know, your experience in anesthesia. How did you get involved in it in the? 1st place anesthesia.  

Kimberly: Yes, you know what, I was working again in the cardiovascular arena and. I was like. I think I need a change, right? I had been there. Things were kind of going in a different direction that I thought I wanted to go in. So, I was like, I need to change. Let me see what's out there. So, I just kind of put myself out there in the market. I really didn't know where I was going to go? I had done cardiovascular for so long; I think it had been like 10 years at that time. And so, I was like, but I knew I wanted something different, something like you said, we are lifetime learners, right? So, I wanted to be able to, I heard you talk about that in another podcast you did, and so I was like, I think, lifetime learning is just so very wonderful. So, I just put myself out there and this anesthesia group reached out to me through a recruiter. And so, I was like anesthesia! Wow! I don't have any experience in that talk about starting like a 5-year-old learning from the ground.  

CJ: Right!  

Kimberly: So I was like, "Sure, I'll interview." I went to the interview and when I tell you the company blew me away from the time that I got to the desk. They were so kind from filling out all of the background information, meeting with HR's meeting, with my direct VP and director. I mean everybody, there was just so wonderful, so patient, so kind. I was like, "Oh, I got to try it." And so, I took the job and even getting into it, they set me up with mentors. Even in that role, because again, I didn't know anything about anesthesia, I came from the surgical world and the proofy world, and I don't know if you know, but it is like a totally different bear. It has its own rules, own coding guidelines, own regulatory. It was like nothing I knew. And so, I took that opportunity and I was able to get partnered up with the right mentors in that organization and they helped me be successful.  

CJ: Well, it sounds like, you know, you're a very self-directed individual. Where can people, like if somebody is starting anesthesia coding like you did at one point, where's a good place to find resources like coding guidance?  

Kimberly: Oh, yes, definitely. Well, you know, I'm all about authoritative resources. I love our YouTube University and Google University. I think they're great. But for me, I always start with the people that make the rules, right? 

CJ: Right!  

Kimberly: So, CMS has a whole anesthesiology center that you can go to, you go CMS and just search it. I tell everybody you don't have to be that great. You can be great as me. Put it in Google. CMS Anesthesiology center. It comes right up and oh my goodness. They have such invaluable resources there they walk you through because there are things everybody know, CMS doesn't always do everything like CPT AMA, right?  

CJ: Exactly!  

Kimberly: And they don't always do everything like our commercial payers. So, being that there's such a force. And they are the pioneers that set the gold standard. You want to know what they say about these topics, and so they have a whole anesthesiology center that they have set up with resources to make you successful.  

In addition to that, I go to the societies that the physicians go to as well. So, you have. ASA, which is the American Society of Anesthesiology. And they do all kind of educational research, all kind of scientific associations and education for physicians in order to be able to even set the standard or raise the standards for the medical practice in anesthesiology. And they focus and even on improving patient care, we benefit from it because it helped us in our business of healthcare; coding, auditing, compliance arena, but they from the beginning, it's all about the patient care. So that is another good resource and then you can seek out good coders like Kelly Dennis, Doris the coder, Doris Brinker. They have excellent, excellent resources on their websites. A lot of them are free resources. They can direct you to good podcasts and webinars to get education. I mean, if you want to learn like you said, there is a way to find it out.  

CJ: Yeah, that's really great, you know, because I know I'm like you. You know, you kind of at some points in your career, you get a little tired of doing the same thing. And so, people do move around and I think it's good. Like I think it's healthy to like you mentioned lifelong learner and just trying to always improve yourself. And so even I guess if some of our listeners aren't going to work full time in anesthesia. Maybe it's time for you listening.  

Kimberly: Yes! 

CJ: Just, you know, expand your horizons a little bit. 

Kimberly: Yes! And I tell them all the time; "Just get the fundamental basics, right?" At least just get the fundamental basics, so you know that what anesthesiology abstracting billing or coding contain of, right? Know what services, just the basic level of knowing. What is the code sets in the AMA CPT coding manual like you don't have to feel like you have to be a scholar and try to self-teach yourself everything to perfection, but at least have the fundamental basics because you never know when topics or situations may come up where someone will ask you, and if nothing else, you want to be that person like they say, be the point person so they know; "Okay, I may not know it all, but I can show you where to go to get you some real good education and information so you could be set up for success," because that's the ultimate goal. We want to know enough to be able to do it right the first time and produce that reimbursement on the back end.  

CJ: Yeah, absolutely! We're going to take a quick break, everybody. We've got some more good questions to ask, Kimberly. So just give us all a moment and we'll be right back.  

Welcome back from the break, everybody talking to Kimberly about anesthesia coding and really one of the questions that I wanted to ask you and you mentioned this briefly, is that anesthesia is so different. What makes it so different and unique from all of the other specialties? You know, we all can look in our CPT book and we already can kind of tell that it's different. So, what's your what are your thoughts?  

Kimberly: Well, one thing I will tell you is that one, they have their own code sets, right? And they start with the zero zeros. And so, unlike all of our other code sets in our MA CPT coding manual that start from the ten thousands all the way to the ninety thousands, one section is the anesthesiology codes and they all start with 00. In addition to that, if you learn and you see how anesthesiology coding is reported. Remember the goal of the anesthesiologists is to support the surgeon. So, when they do that, support of the surgeon, they don't bill every CPT code as a surgeon would. They bill it based on the highest procedure performed and the base unit that's performed. So with anesthesiology, you also have two additional coding references that you don't use as a surgical or proofy coder. You have to use your CROSSWALK, your ASA CROSSWALK book, and your SARVG book that relevant value guide and that's where you get your base units from to be able to equate which is the highest procedure when you're doing that CROSSWALK from what the surgical procedure is.  

In addition to that, one more unique thing about anesthesiology coding is every single base unit CPT code that you build will have a modifier. The modifier is what identify who the provider is that performs the service. And what I mean by that is in anesthesiology you can have an anesthesiologist, right? The actual MD, but you also can have the CRNA for that certified registered Nurse anesthetist. You could also have a certified anesthesiology assistant, that's CAA. And so, depending on the modifier, the modifier lets you know who actually did the service, who was the actual provider? Was it the physician, or was it one of the assistants? 

CJ: And that's been where I've learned, again I'm not an expert in it, but where there's been some compliance issues sometimes like the coding and the billing might be done as if the physician did the service and maybe that pays more. But maybe the physician was directing or supervising and there's these different levels of clinical supervision and oversight, and then that can equate to, you know, how you're billing. Tell us a little bit more about that. I know it can be complex, so I don't mean to put you on the spot if it's too complex, but maybe a high-level overview.  

Kimberly: Well, at a high-level overview, we all know when it comes to medical direction. Again, CMS is your paramount to find how you're supposed to do that and what are the seven steps to medical direction because CMS has seven steps that they have outlined that have to be done if you're going to do what's called medical direction.  

In addition to the medical direction, they set limits so you can only have medical direction on two to four cases at the same time. The minute you are more than four, you're no more during medical direction and know that medical direction is an all or none. You either meet all of the seven steps or you don't. You can't meet four and still have medical direction. And so at a high level, I say if you're going to do anything that has to do with medical direction, especially if you're under Medicare and you're having to follow Medicare criteria, you definitely want to go to their website and identify what those standards are.  

Now, even if you're doing supervision, it's important to know for medical necessity, right? And your medical documentation that you're outlining those things correctly. You are so right when you say that using the improper modifiers, especially to identify those providers that will give you a compliance risk that you do not want to have to deal with, right? Because they will dig into that documentation in the minute, they see that you're billing for the incorrect provider that is going to be a red flag and that's going to cause your company to be having exposure to some risk that you really don't want to have to deal with. You never want to have documentation that don't support the provider of service that you're billing out.  

CJ: Yeah, and it can be, you know you're walking a line, right? Like you want to get reimbursed every penny that you deserve that's legitimate. And so you're trying to be efficient and maximize your use and stuff, but sometimes you can start to get this creep. And what I've seen, maybe you can tell me a little bit about it with the time methodology. A lot of a lot of the documentation, right? Like anesthesiologists will mark, they'll sign in when they're when they're in the room and maybe sign out and then on the back end when things get audited, they're looking to see what the overlap is, right?  

Kimberly: That's right. Oh yes, those concurrencies absolutely. They call them concurrencies and they do watch it closely. Because you're right that anesthesia, that's another tricky part about anesthesia. You know, when you deal with a surgeon and the surgeon does the procedure, you have your surgeon in there, they start the time they do the procedure. When the procedure ends, they stop and that's over, right?.  

CJ: Right? 

Kimberly: With anesthesiology It's a little different because they have free work, they have that pre anesthesia work they have to do. And then they have that post anesthesia work they have to do to stabilize that patient before the patient go over to pack you. So it's not a soon as you get there starting done, right? They have to, it starts when anesthesiology gets there to prepare the patient, but they could do a lot of pre work to get that patient prepared and then they have to stay there to make sure that patient everything goes right with that patient that they wake up from the procedure. They're not having any kind of resuscitation or cardiopulmonary issues that everything's going great, their vitals are good and then they transfer them over to the recovery unit, also known as the PACU. So that anaethesia time, it's very important that it's documented as well.  

A tricky thing is if you've never looked at one of those time logs, you know they have these little time logs they use and they take them and they're normally in like 15 minute increments. Again, you want to take your time anthology with your pair because everybody doesn't honor the 15 minute increments to 1 unit, but that's the typical, but yes.  

CJ: Exactly!  

Kimberly: And when they take it and that's how you know what your anesthesia time is, but you want to be careful because they can supervise more than one case at a time, but you can't be in more than one place at a time, right? The one person, and that's when those concurrencies come, right? 

CJ: Exactly! Exactly!  

Kimberly: That time of those concurrencies and making sure; "OK what time did they say they were here? What time did they leave? Do any of those overlap? You know, how can we make sense of those concurrencies in anesthesia," that is very much so something that you have to watch.  

CJ: And it's kind of like maybe this is a loose analogy, but like, you know, we talk about the outpatient arena and that like a physician's office where they might have nurse practitioners and you have, you know if you're billing incident two and those sorts of things, you have to think strategically as a business and as an organization, "Do I even want to do that?" Right? Or; "Do I just want the nurse practitioners to see patients under their own license? Just do it.  

Kimberly: Yes! 

CJ: And it's similar in anesthesia, right? Where sometimes it might just make more sense from a practicality or an efficiency scheduling, just let the CRNAs do what they do, right? Is that part of the conversation?  

Kimberly: Yes. That's the risk. Yes, that's it. Yes, absolutely. And I'm going to tell you, I work for an organization, when you bring up that incident two, which I know is a whole another topic, we're not talking about, right?  

CJ: Right!  

Kimberly: But we've elected not to do incident two and it's for the very reason that you're identifying, which also could affect the anesthesia world. It's like you have to analyze your risk and say; "Is it worth it? Is it worth going down this road where we may not have the supported documentation listed as we need it to? To get the additional percentages that come with it," right?  

And so I'm like you, I want my providers to be reimbursed for every single dime of everything that they do that warrants what they did for that service, cause they work hard enough, right? And we every time we turn around some, some rate is being deducted for them. So no, I'm like you, I want them to be fully reimbursed. But we want to also make sure that we're not putting ourselves at any risk, no risk exposure, and we're documenting and following things exactly as they happened. I totally agree with that.  

And you're right, sometimes you have to say; "You know what? We're just not going to do it. We're going to let our CRNAs do these procedures. We'll let them report it. We'll let our CAAs do these procedures. We as anesthesiologists will report what we can, but we're not going to get into chancing us being exposed to risk because things are not working properly."  

CJ: Yeah, because as I've worked with clients, I usually have to start off the conversation with that. They say; "I want an audit of this and that and we want you to tell us what to do." Well, it's like, well, no, you need to understand what the options are because there's many ways to proceed. And these are some of these are business decisions. Some people want to take on the complexity of doing, you know, maximizing things. Others just say, you know what it's not worth the risk, but those aren't decisions that a consultant can usually make. You can provide them advice. And so, that's why I kind of brought that one up for sure.  

Kimberly: Absolutely! And you know what, I always recommend too, CJ? I say, do your internal policies because sometimes some of these issues can be great, right? There's not really a policy from the payer. There's not a policy that you feel you can hold for CMS. It doesn't mean that you don't need to create one, then you need to create one like you said, make it a business decision for your practice. Make it a business decision for your entity. And you say; "When we have concurrencies and we have cases of this sort or we have physicians that are doing certain services and they need the support of CRNs or CAAs. Okay, this is our internal policy of what we're going to allow to happen in those circumstances. And this is what we're not going to allow to happen." Because at least if you get risky exposure and let's say you have to get some of the authoritative organizations to step in, like CMS, OIG Jayco, well at least then you can say; "Hey, we knew this might be an issue. This is our policy. There was no definitive guidance out there for us to follow, but this is the policy we came up with to lessen our risk exposure." If nothing else they can see you're trying in good faith to do the right thing, right? And that should be a win.  

CJ: Exactly! The other thing can really, and I know we're getting kind of close to the end of our time. But I just wanted to ask you real quick is you know, I know we've spoken a lot about the OR and these anesthesia codes that start with 00, but a lot of anesthesiologists also do like pain management clinics or they may do kind of pain treatments that aren't in the 00 codes, have you...?  

Kimberly: Oh, yes, yes! Like our nerve blocks. Yes, we. And we have 60,000 code series that they can do for nerve blocks. Also, they can do simultaneously the 30,000 series codes if they're doing any kind of A-lines, right? Those arterial lines are those endotracheal tubes, those, ETTs. Anytime they have to do any line placements, you're correct. So they do a lot of those anesthesia codes, but they can do 60,000 and 30,000 if they're doing cath placements or if they're doing any kind of blocks for nerves for cause a lot of times they have post pain blocks that they can do too, if they're recommended to be done by the surgeon's request and then I can't forget our qualifying circumstances. Those are 20,000 codes as well. Those, 99140, 99315. So absolutely there are other code sets in the coding manuals that they can code as well.  

CJ: Exactly! Yeah, absolutely. And, yeah, the time has kind of just gone so quickly, but I want to give you an opportunity to share any last-minute thoughts about anesthesia or about anything and you know as we wind down here.  

Kimberly: Absolutely! Well, one thing I do want to say, I referred everybody to ASA's website and I hope you can go and check it out today because just recently in the month of March ASA just publicized that certified anesthesia assistants are now authorized to practice in Washington state and so that is a new thing. They're going to be effective by Senate Bill 5184 that was just passed. And I think it's effective June of 2024. And so that's just another point to point out that if you go to these resources like ASA and CMS, they will give you good guidance because know that every state doesn't allow CAAs to do this type of practicing. So that's how we stay in the know. That's how we know what's going on when things are changing. And, Christine Hall, my good friend, always says; "If we cannot count on anything, we can count on change." And just when we get used to something, one way they would change it up on us. So, we have to make sure it's our own us to make sure we're looking at these authoritative resources so we know when the changes are happening.  

CJ: That's right!  

Kimberly: But thank you again. It has been my honor to serve. Yes, definitely have everyone connect with me on LinkedIn and look for me shortly that medical institute, again I just love it so much for you asking for my insight on any of this regarding anesthesia.  

CJ: Yes, Kimberly, thank you so much. And some of those links and things we can include in the show notes, if you'll share those with us, if you're LinkedIn and any other these resources that you think helpful and I just love what you said earlier about we need you know in our roles we need to be the ones who are proactively on top of things. So the fact that you know you are identifying resources. You know that Washington state has just recognize CAAs and so that's part of our job too. Is having the most current information and getting that to our teams and our organizations and that you know that's proactive work. And so, I love that attitude.  

Kimberly: Yes! Correct. Absolutely yes! And it makes you invaluable, right? Because maybe your director or your physicians or your practice administrator didn't know. So now you're the one bringing it to them. So, they look to you as a good resource of good solid information.  

CJ: Yes! Well, Kimberly, thank you so much, you're a pleasure to speak with you and a wealth of knowledge.  

And thank you to all of our listeners. Thank you for listening to another episode. We encourage you to share this with friends. We always encourage you to share with us other topic ideas or guests that you think might have something to share on the podcast. We'd love to explore that with you and until our next episode, please take care and be safe, everyone. Bye bye!