User Guide — Anesthesia Billing Using Time Sheets

A member of the practice administrative staff creates a "time sheet batch" in athenaOne, via the Manage Anesthesia Time Sheet Batches page. A time sheet batch corresponds to a daily shift schedule for the anesthesiologists who are directing providers. Each date of service requires one or more time sheet batches.

1. Display the Manage Anesthesia Time Sheet Batches page: On the Main Menu, click Claims. Under CHARGE ENTRY, click Anesthesia Time Sheet Batches.
2. At the bottom of the page, click the link to create new time sheet batch. The Time Sheet Batch page appears.
   
3. Name — Enter the name of the time sheet batch.
4. Service Date — Enter the date of service for the time sheet batch.
5. Directing / Supervising providers — From the list, select the usernames of the directing providers who work concurrently to provide anesthesiology services on that day. (athenaOne automatically opens one time sheet for each provider selected.)
6. Notes — Enter any notes about the time sheet batch.
7. Click Save. The list of selected providers appears below, with links to view/edit and view concurrency graph for each directing provider's time sheet.
   Note: When the time sheet batch is saved, athenaOne opens time sheets for each directing provider in the batch.

1. Display the Manage Anesthesia Time Sheet Batches page: On the Main Menu, click Claims. Under CHARGE ENTRY, click Anesthesia Time Sheet Batches.
2. Click the view/edit link for the desired time sheet batch. The Time Sheet Batch page appears.
3. Click the view/edit link next to All Providers. The Time Sheet page for the providers in the time sheet batch appears.
4. Click the Add time sheet row link. Data entry fields appear for the first row in this time sheet.
5. Patient ID —
   • If the patient is already registered in your practice, enter the patient ID number. You can also enter a period to access the Find patient tool.
     Note: The patient lookup tool available through the time sheet returns only patient ID numbers registered in the provider's provider group. Names that appear without an ID number are not registered in the provider's provider group. You must register the patient in the provider's provider group before you can select the patient.
   • If the patient is new to your practice, enter a period to access the Find patient tool, then click register new patient to display the Patient Registration page. After you save the new registration information, click the return to timesheet link in the Task Bar. The new patient information then appears in the time sheet row.  

6. Anesthesia Case — Select [add new]. The data entry fields appear for the new case.

Enter anesthesia case information

7. Procedure code — Enter the CPT surgical code in the CPT field, or enter a period to access the Procedure Lookup tool and select the code from the list. After the CPT code is entered, athenaOne returns the list of corresponding ASA codes in the ASA menu.
   Note: To create a case containing non-time-based procedures only, select the Non-Anesthesia option located under the CPT field. You can add additional non-anesthesia procedures to the case.
8. ASA — Select the corresponding ASA code. An asterisk indicates a local mapping.
   Note: You can create local CPT—ASA code mappings using the Local Anesthesia Code Mappings page.
9. Non-Anesthesia — Select this option if the service or procedure is not a time-based anesthesia service. If selected, this option tells athenaOne that start and stop times and ASA codes are not needed.
   Note: To add a non-anesthesia procedure to an anesthesia case, click Add Non-Anesthesia Procedure to this Case (below the Diagnoses field). Input fields appear for you to enter the procedure code, diagnosis codes, and unit for the non-anesthesia procedure.
   
10. Diagnoses — Enter the diagnosis codes used to support medical necessity. You can type a period to search for the codes by entering an ICD-10 code, ICD-9 code, or SNOMED term.
    
11. Service department — Select the location where services were rendered.
12. Operating room — Select the operating room where the service was rendered.
    Note: This menu appears if you have defined operating rooms in your practice via the Operating Rooms page.
13. Hospitalization dates — Enter the from and to dates of the patient's hospitalization in MM/DD/CCYY format.
14. Referring provider — Click the Choose/view link to access the Referring Provider Lookup tool and select the provider from the directory of referring providers.
15. Surgeon — Click the Choose/view link to access the Referring Provider Lookup tool and select the surgeon from the directory of referring providers.
16. Anesthesia type — Select the type of anesthesia administered.
17. Physical status — Select the physical status of the patient.
18. Extenuating circumstances — Select any extenuating circumstances.
19. Medical direction — Select "Incomplete" if fewer than seven of the direction requirements have been met (see the field reference below for more information). Otherwise, select "Complete." The meaning of the (default) option is determined by your practice settings.
20. Adverse events — Select any adverse events that occurred when service was rendered.
    Note: This field appears only if you created an adverse events code set via the Adverse Events page.
21. Post operative complications — Select any post operative complications that apply to this anesthesia case.
    Note: This field appears only if you created a list of the post operative complications used in your practice via the Post Operative Complications page.
22. Case review — Select this option if you plan to include this anesthesia case in a future review or study.
23. Notes — Enter any notes about this anesthesia case.
24. Click Save to create the anesthesia case. The new case appears listed at the bottom of the page and in the list of anesthesia cases at the bottom of the Time Sheet Batch page.

To add non-anesthesia procedures to this case

25. To add non-anesthesia procedure codes to this case, click the Add Non-Anesthesia Procedure to this Case link. Additional CPT and Units fields appear:
    1. CPT — Enter the procedure code for the non-anesthesia service.
    2. Units — Enter the units for the non-anesthesia service. If you leave the Units field blank, it defaults to 1 when the claim is created.
    3. Diagnoses — Click the Add Diagnosis Codes link if diagnosis codes for this procedure differ from the diagnosis codes entered for the primary code on the case. Enter the diagnosis codes in the input fields provided.
    4. Continue to add as many non-anesthesia procedures as needed. All procedures entered in a single case will be created as separate charge lines on a single claim.
    5. Click Save at the bottom of the page to save the case.

After you create an anesthesia case, it appears listed in the Anesthesia Case menu on the Time Sheet page for every time sheet entry (i.e., every line item) with a matching patient ID, on every time sheet in the batch where the anesthesia case was created.

To add non-time-based procedures to an existing case, click the Edit case link to re-open the case and make your changes or additions. Click Save when you are finished.

As you add entries to the time sheet, the Anesthesia Case menu is populated when you enter the patient ID in the Patient ID field.

For every time sheet entry, you must select an existing anesthesia case or add a new anesthesia case.

1. Display the Manage Anesthesia Time Sheet Batches page: On the Main Menu, click Claims. Under CHARGE ENTRY, click Anesthesia Time Sheet Batches.
2. Click the view/edit link for the desired time sheet batch. The Time Sheet Batch page appears.
3. Click the view/edit link for the provider's name in the list of providers at the bottom of the page. The Time Sheet page for the provider appears.  
4. Patient ID — Enter the patient's ID number. You can enter a period to access the Find patient tool. After you populate the Patient ID field, athenaOne populates the Anesthesia Case list with all anesthesia cases for that patient.
   Note: The patient lookup available through the time sheet returns only patient ID numbers registered in the provider's provider group. Names that appear without an ID number are not registered in the provider's provider group. You must register the patient in the provider's provider group before you can select the patient.
5. Anesthesia Case — Select the anesthesia case where the anesthesia service was provided for this entry. If the Anesthesia Case menu is empty or if the anesthesia case is not listed, select [add new] to create the new anesthesia case (see instructions below). After the case is created, it appears listed here so that you can select it. You can also select [add new] to display case input fields.
   Note: Anesthesia cases are also created using the Anesthesia Cases page.
6. Start Time and End Time — Enter the start and end time of the anesthesia service.
   Note: Time is entered in 24-hour format. Times entered are exclusive. In other words, 08:00—08:30 = 30 minutes.
7. Directing / Supervising Provider — Select the username of the directing or supervising provider.
8. Directed / Rendering Provider — Select the username of the provider who rendered the service.
   Note: If the directing or supervising provider personally performed the service, select the username of the directing provider as the Directed / Rendering Provider.
9. Applies to Concurrency? — If you want to override or exclude a service or procedure from the concurrency count, select No.
10. Override Date? — For C-section services, if the epidural dates of service differ from the C-section date of service (as may happen if the procedures occur during the midnight hours and the date changes). Select this option for the procedure with the earlier date of service. When you do, date fields appear below the Start Time and End Time fields. Complete the start date and end date fields for the epidural procedure.
11. Click the Save button to save the data in the row.  
    Note: When you save the time sheet, athenaOne recalculates the number of concurrent cases for the time sheet. The concurrency value for each service appears below the Applies to Concurrency? field.
12. Continue to enter data from the provider's paper time sheet in the same manner.
13. After all the data from the provider's paper time sheet has been entered and saved, click the button to Save as Completed.

From the Time Sheet page, you can also view a concurrency graph that shows the concurrency calculation. Concurrency calculations consider cases in all time sheets, including multiple time sheets for the same provider on the same day.

athenaOne uses the time sheet batch record and the time sheet to ensure that all services are entered for a date of service. This ensures accurate concurrency counts by athenaOne.

Note: Anesthesia concurrency calculations include cases that span midnight to accommodate overlapping cases in a previous or subsequent time sheet batch. The concurrency graph view shows cases in other time sheets when those time sheets contain cases that are concurrent with a case that spans midnight.

You can click the Save & View Concurrency Graph button at any time to view a graphical representation of the provider's concurrency level.

1. Display the Manage Anesthesia Time Sheet Batches page: On the Main Menu, click Claims. Under CHARGE ENTRY, click Anesthesia Time Sheet Batches.
2. Under the Open Time Sheet Batches heading in the Workspace, click view/edit for a batch that shows claims not yet created in the Status column. The Create Anesthesia Claims Worklist appears in the Task Bar.
   
3. Cick the view time sheet batch page link at the bottom of the Create Anesthesia Claims Worklist to display the Time Sheet Batch page in the Workspace.
4. Scroll down to the section called Anesthesia Cases in this Batch.
5. Click the view/edit link of the anesthesia case that you want to remove from the parent-child relationship. The Anesthesia Cases page appears in the Workspace for that anesthesia case, showing the current parent case — this is the case that appears in the Create Anesthesia Claims Worklist, opposite the create claim link for the group of entries.
6. Parent Case — Deselect the parent case and make the selection blank.
7. Click Save at the bottom of the Anesthesia Cases page.
8. Right-click anywhere in the Worklist, and select Refresh from the menu to update the Worklist.
   The Worklist now shows the time sheet entry with its own create claim link. You have successfully removed the time sheet entry from the group.
   

A time sheet batch is complete when all its directing provider time sheets within the batch have been assigned a status of complete.

1. Display the Manage Anesthesia Time Sheet Batches page: On the Main Menu, click Claims. Under CHARGE ENTRY, click Anesthesia Time Sheet Batches.
2. Click the view/edit link for the time sheet batch that is ready to be closed. The Time Sheet Batch page appears.
3. Click Save as Completed.

After the time sheet batch is marked as completed, the Status column on the Manage Anesthesia Time Sheet Batches page indicates the number of claims that should be created for that batch. For example, the message "0 of 4 claims created" indicates that the batch should produce four anesthesia claims.

Note: After all the claims in the time sheet batch are created, athenaOne resets the status of the time sheet batch to closed.

Late charges are anesthesia charges received after concurrency has already been calculated and all other charges for a date of service have already been entered into athenaOne. When late charges are entered, you need to recalculate concurrency for the affected time sheets and time sheet batch.

Note: This function is available only if your practice has the Reopen Time Sheet Batches practice setting enabled.

1. Display the Manage Anesthesia Time Sheet Batches page: On the Main Menu, click Claims. Under CHARGE ENTRY, click Anesthesia Time Sheet Batches.
2. Click view/edit to select the time sheet batch that needs charges added or updated (the batch will have a completed status, such as "2 of 2 time sheets completed"). The Time Sheet Batch page appears.
3. Under the Time Sheets in this Batch heading, click view/edit to select one of the individual time sheets, or click view/edit for the All Providers view. The Time Sheet page appears.
4. Scroll to the bottom of the page and click Reopen Time Sheets.
5. Enter or edit the late charges (i.e., the additional services) into the time sheet.
• If the patient claims have not yet been completed, athenaOne automatically modifies them in the Create Anesthesia Claims Worklist.  
• If the claim has been previously created and the newly entered charges have a material effect on the previously entered charges (e.g., a change in concurrency level in which the changes in billed time have not yet been flagged to appear in the exception reporting), athenaOne highlights the claim in red in the Create Anesthesia Claims Worklist.
6. On the Time Sheet page, click Save to save the new charges, and then click Save as Completed to save the completed time sheet.
7. On the Time Sheet Batch page, click Save as Completed to complete the time sheet batch. The Create Anesthesia Claims Worklist appears in the Task Bar with the Create all claims link at the top of the worklist. Any claims that are flagged for concurrency are highlighted in red.
8. In the Create Anesthesia Claims Worklist, click the linked claim number of any red-highlighted claim to display the Claim Edit page in the Workspace.

On the Claim Edit page 

9. On the Claim Edit page, scroll to the bottom of the page and locate the box with the red message: Edits to the time sheet resulted in the following changes. You see a description of the resulting changes to the time sheet (for example, "Concurrency level changed from Multiple Direction to Supervision").
10. You now have two options:
• Click Save Claim and Clear Flag to save the claim and remove it from the Create Claim list as an exception. athenaOne removes the red highlighting from the claim on the Create Anesthesia Claims Worklist and adds the description of the resulting changes to the Claim Notes section on the Claim Edit page. The claim remains in a Hold status so that you can re-drop the claim if needed.
• Click Reload Claim from Time Sheet to re-create the claim using the new information available in the time sheet. Next, click Save Claim and Clear Flag to remove the claim from the Create Anesthesia Claims Worklist.
  Note: If a claim's charges are "Reloaded from the Time Sheet" and saved, athenaOne does not re-drop the claim. A note appears in Claim Notes describing the change that was made. The claim will remain in a Hold status, and you can manually re-drop the claim if needed.  
  
  Tip: You can quickly locate charges with concurrency issues. On the Manage Anesthesia Timesheet Batches page, under the Open Time Sheet Batches section, the Status column of the time sheet batch provides a count of claims flagged because of concurrency issues.

1. Display the Manage Anesthesia Time Sheet Batches page: On the Main Menu, click Claims. Under CHARGE ENTRY, click Anesthesia Time Sheet Batches.
2. Under the Open Time Sheet Batches heading in the Workspace, click view/edit for a batch that shows claims not yet created in the Status column.
   The Create Anesthesia Claims Worklist appears in the Task Bar.
   
3. Click Create all claims at the top of the Task Bar.
   The Create Anesthesia Claims Batch page appears in the Workspace.
   Note: On the Create Anesthesia Claims Batch page, you can see how units are calculated by pausing your cursor over the units (in the U column).
   
4. Insurance — Select the correct insurance, which can be an insurance package or a case policy. The default value is the patient's current primary insurance.
   Note: When you change the primary insurance, the procedure modifiers, units, and charges (which are based on anesthesia billing settings) are updated automatically. athenaOne highlights these changes in yellow.
5. Click Approve All to approve all charges.
   Note: If you decide not to create claims for all the charges in this batch, you can click OK for each charge (row) that you want to approve.
6. Click Create Claims to create claims for the charges that you approved.

The Create Anesthesia Claims Batch page reappears in the Workspace, with the new claim number and claim status under the Claim column. The Create Anesthesia Claims Worklist in the Task Bar has links to the created claims. The worklist is now organized to show claim status, so that you can work claims that are holding for front-end claim rules within the time sheet workflow.

1. Display the Manage Anesthesia Time Sheet Batches page: On the Main Menu, click Claims. Under CHARGE ENTRY, click Anesthesia Time Sheet Batches.
2. Click the view/edit link for a completed time sheet batch (one where the Status column reads "0 of n claims created"). The Create Anesthesia Claims Worklist appears in the Task Bar.
3. Review the information under the Patient column of the Create Anesthesia Claims Worklist.
   Note: One patient can have multiple time sheet entries (rows) and create claim links.
4. Click the create claim link for the claim that you want to create. The advanced view of the Charge Entry page appears in the Workspace.

On the Charge Entry page 

5. Verify that the selected Rendering provider and Supervising provider are correct.
   Note: The provider you select using the Supervising provider field typically appears as the rendering provider on the claim.
6. Scroll down to the charge information (under the "Service Type Add-Ons" heading) and verify that the CPT codes and modifiers in the Procedures field are correct.
7. Verify that the codes entered in the Diagnosis codes fields are correct.
8. In the box labeled Anesthesia, read the text of the note explaining how the anesthesia units for this charge were calculated.
9. Scroll down to the Create Claim button and ensure that the diagnosis and procedure codes are known to your practice.
10. Click Create Claim to create the claim.

If your practice staff determines that a claim was billed or sent to the wrong payer, you can select a different insurance package to bill (including SELF-PAY, which is treated as a distinct insurance package).  

When you select a new insurance package, a pop-up window appears asking if you want to reload the data from the time sheet.

1. Select Yes so that the claim will be reformatted correctly for the new payer.
2. Make additional changes and save the claim.

If the original claim was formatted on a single claim and the new payer requires separate claims, athenaOne will automatically split the claim for you. A claim note will be added to the claim with a link to the newly created sibling claim.

If the claim was originally split and the sibling claim has not yet been billed:

1. A dialog box warns you that all data on the sibling claim will be voided. Click OK.
2. On the Claim Review page, the Claim Notes section now shows these three important points:
• The claim was originally split.
• The primary payer has been changed.
• The sibling of the original claim has been deleted. You can select Yes, but this does not cause athenaOne to split the claim automatically.

If the claim was originally split and the sibling claim has been billed or has anything posted on it, follow the same process as above. On the Claim Review page, the Claim Notes section shows:

• The claim was originally split.
• The primary payer has been changed.
• The sibling of (link to claim) is no longer valid; the practice must review the charges on the claim.

Click the link to the sibling claim. The Claim Notes section indicates that the primary payer on the original claim has been changed and that this claim is no longer valid but is in PRIMARY HOLD for review of the charges on the claim, with the kick code ANESTREFORMAT.

1. Display the Claim Edit page for a claim that has been split.
2. From the Primary Payer menu, select the new insurance package. A dialog box warns you about changing the primary payer. Click Yes to refresh the Claim Edit page with the new insurance package.
3. Review the claim and make any additional edits that may be needed.  
4. Click Save Claim at the bottom of the page. A dialog box warns you that all data on the sibling claim will be voided. Click OK. The Claim Review page appears with the Claim Notes section showing the following information:
• The claim was originally split.
• The primary payer has been changed.
• The sibling of the original claim has been deleted.

Because the claim formatting and claim rules for anesthesia claims differ significantly from other types of claims, athenaOne provides a special charge entry workflow for anesthesia claims using a suite of specialized pages:

• Manage Anesthesia Time Sheet Batches
• Time Sheet Batch
• Time Sheet
• Anesthesia Cases
• Create Anesthesia Claims Worklist
• Create Anesthesia Claims Batch

In addition, there is also a set of billing admin pages related to setup for anesthesia billing:

• Local Anesthesia Code Mappings
• Local Anesthesia Base Unit Values
• Adverse Events
• Operating Rooms
• Post Operative Complications
• Local Anesthesia Billing Settings

An anesthesiologist may direct the anesthesia services of multiple patients at the same time. The term "concurrency" is used to describe this scenario. An anesthesiologist who manages the services of up to four Certified Registered Nurse Anesthetists (CRNAs) or Anesthesia Assistants (AAs) is called a "directing provider." An anesthesiologist who manages the services of more than four CRNAs or AAs is referred to as a supervising provider.

The directing provider typically carries a paper time sheet to record the services provided during the day or shift. This time sheet looks very different from an ordinary billing slip because it reflects multiple patients, concurrent services, and the direction or supervision of CRNAs or AAs. The time sheet is an itemized listing of all the activity of all their anesthesia cases for a day.

For anesthesia time sheet batches that have a date of service on or after October 1, 2015, you must include ICD-10 codes in the Diagnoses fields on the Anesthesia Cases page. Use the ICD-10 lookup tool to search by ICD-10 code, ICD-9 code, or SNOMED term. Also, warning messages may appear for some time sheet entries, informing you of updates that you need to make to comply with ICD-10. Review these messages and make any changes necessary to add or update ICD-10 or ICD-9 codes.

For payers that are not prepared to accept ICD-10 codes, athenaOne converts ICD-10 to ICD-9 codes only when you

• Mark a time sheet batch as complete.
• Approve the ICD-10 to ICD-9 code mappings (see ICD-10 to ICD-9 Mapping).

After you approve the ICD-10 to ICD-9 mappings, ICD-10 codes are automatically downconverted to ICD-9 when you complete a time sheet batch for a payer that requires ICD-9 codes.

If you do not approve the ICD-10 to ICD-9 mappings before the ICD-10 transition date, you will not be able to enter ICD-9 codes in anesthesia time sheets or create claim batches that require ICD-9 codes. Instead, you will need to enter ICD-9 codes manually on the Charge Entry page.

Every time a time sheet is saved, athenaOne automatically checks the time sheet for exceptions and flags the scenarios listed below. You should review any exceptions on the time sheet and make the needed corrections before marking the time sheet as completed and creating claims.

• Provider Involved in Multiple Cases: athenaOne identifies instances where a provider is reported as rendering multiple services at the same time or personally performing services while directing the services of another provider at the same time.
• Overlapping Services on Patient: athenaOne identifies instances where multiple providers were reported as working with the same patient at the same time.
• Overlapping Services in Multiple Locations: athenaOne identifies instances where a provider is reported as providing services at multiple physical locations at the same time.
• Addon Code without Main Code: athenaOne identifies instances where there is a case for an add-on service (e.g., 01968) without an adjacent case for the main service.
• Concurrency Higher than Allowed: athenaOne identifies services with a higher concurrency value than allowed to qualify for medical direction.

If an exception fires, the providers and cases involved appear under the Exceptions in this Time Sheet heading at the bottom of the Time Sheet page. Each exception is linked to the corresponding anesthesia case.

In addition, each time a time sheet batch is saved, athenaOne automatically checks for exceptions. These batch exceptions appear under the Exceptions in this Batch heading at the bottom of the Time Sheet Batch page.

You should review all exceptions to determine the correct action

athenaOne assumes that services rendered by the same provider should be reported together on the same claim when athenaOne generates claims from an anesthesia time sheet. For example, non-anesthesia cases are linked to a time-based anesthesia case performed by the same rendering provider in a parent-child relationship. On the Create Anesthesia Claims Worklist, time sheet entries that are translated together onto the same claim share the same create claim link.

The Create Anesthesia Claims Worklist provides the list of all the anesthesia claims that should be generated based on the services recorded in the time sheet. As part of the claim creation process, the athenaOne system uses special logic to perform a series of anesthesia "translations," namely,

• Designations for "first," "last," and "longest," according to your practice settings
• MD only, CRNA only, Split Charges, or Split Claims per payer guidelines
• Assignment of modifiers for level of direction/supervision per payer guidelines
• Assignment of Physical Status modifiers per payer guidelines
• Creation of separate charges for extenuating circumstances (e.g., for extreme age, use of hypothermia, use of hypotension) per payer guidelines
• Calculation of anesthesia total units (base units + time units + P-Mod Units)

You can create all the claims for a time sheet batch at once (charge entry is automated), or you can create each claim individually (this option requires that you review the Charge Entry page).

Your practice can use the Do we bill for this provider? field on the Providers page to accommodate an anesthesia-specific scenario. Select No to include this provider in the anesthesia workflow concurrency calculations, while still not billing for this provider's services.

For example, if anesthesiologists at your practice direct CRNAs and you bill for the anesthesiologists but not the CRNAs, you create the CRNAs as providers and select No in this field. When you make time sheets for the CRNAs, athenaOne creates claims only for the billable providers, but does include the CRNAs in the concurrency calculations and applies the appropriate anesthesia modifiers.

In the Report Library, under the Other tab, you will find a set of recommended reports related to anesthesia billing.