Anesthesia Alert Reference
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This page describes the anesthesia alerts your team meets most often. It groups them by topic: medical direction and TEFRA, physical status and MAC modifiers, anesthesia time, procedure billing, claim building, relief and handover, and post-operative pain rounds. It does not list every anesthesia alert.
Every alert carries a type, a severity from 1 to 10, and a suggested reviewer role. Read How Alerts Reach Your Workflow for what the types and severities mean.
These alerts cover Medicare medical direction billing and the seven CMS TEFRA requirements.
| Alert | Alert id | Type | Sev | When it fires and what to verify |
|---|---|---|---|---|
| TEFRA requirements met | tefra_all_requirements_met |
| INFORMATIONAL |
| 2 |
| All seven CMS medical direction requirements are documented. This is a confirmation. No action is needed. |
| TEFRA requirements not met | tefra_requirements_unmet | Set by configuration (shipped default COMPLIANCE) | Set by configuration (shipped default 8) | One or more of the seven requirements are not documented. The alert names each unmet requirement. Read the record for evidence, then follow your facility's TEFRA protocol. Note: some facility elections resolve unmet requirements automatically (for example, drop to non-directed CRNA billing) and raise NO alert at all -- if you never see this alert, confirm your election with your Hank representative rather than assuming requirements always pass. |
| No provider times documented | med_dir_no_provider_times | HARDSTOP | 9 | The autocoder found providers on the case, but none of them have start and end times. Medical direction modifiers need provider times. Add times for at least one provider. |
| Provider times inferred from case events | provider_times_inferred_from_case_events | COMPLIANCE | 4 | A solo provider has no staff times, so the autocoder used the case event times instead. Confirm the provider was present for the whole case. |
| CRNA billing non-directed (QZ) | med_dir_crna_alone_qz | INFORMATIONAL | 3 | A CRNA is the only provider on the case, and your facility allows non-directed billing. The autocoder applies QZ. Confirm the CRNA worked without physician direction. |
| Medical direction modifier mismatch | meddir_qk_qx_mismatch | HARDSTOP | 8 | The count of QK modifiers does not match the count of QX modifiers. Proper medical direction pairs them one to one. Check each physician line against its CRNA line. |
| Medical direction exceeds 4:1 ratio | meddir_exceeds_4_to_1 | HARDSTOP | 9 | The claim carries more than four QK modifiers. CMS limits medical direction to four concurrent cases per physician. Verify the case count. |
| Direction modifiers without medical direction | meddir_modifiers_not_requested | HARDSTOP | 8 | QK or QX modifiers are present, but medical direction was not requested for this case. Either enable medical direction or remove the modifiers. |
| CRNA has AA modifier | crna_has_aa_modifier | HARDSTOP | 8 | A CRNA line carries AA, which means the anesthesiologist personally performed the service. A CRNA cannot use AA. Change it to QZ or QX. |
| Alert | Alert id | Type | Sev | When it fires and what to verify |
|---|---|---|---|---|
| ASA physical status modifier missing | asa_modifier_missing | FINANCIAL | 6 | The note documents an ASA physical status, but the matching P-modifier is not on the claim. P3 and above add base units, so this can cost revenue. Add the correct P-modifier. |
| ASA physical status modifier mismatch | asa_modifier_mismatch | HARDSTOP | 7 | The P-modifier on the claim does not match the status in the note. Compare the two and correct the modifier to match the record. |
| Physical status P3 or higher without comorbidity | physical_status_unsupported | FINANCIAL | 5 | The claim bills P3, P4, or P5, but no supporting comorbidity diagnosis is coded. Add the supporting diagnosis if the chart documents one. Otherwise lower the physical status. |
| MAC modifier missing | mac_modifier_missing | FINANCIAL | 6 | The record documents Monitored Anesthesia Care, but no QS, G8, or G9 modifier is on the claim. Add the correct MAC modifier. QS is the default. |
| MAC modifier on a low-trust source | mac_modifier_low_trust | HARDSTOP | 7 | A MAC modifier was suppressed because the anesthesia type came only from the surgeon note, or because an anesthesia record documents general anesthesia. Confirm the type from the anesthesia record. |
| G9 without severe cardiopulmonary condition | g9_modifier_unsupported | FINANCIAL | 6 | The claim carries G9, but no severe circulatory or respiratory diagnosis supports it. Verify the condition is documented and coded. If it is not, use QS instead. |
| PT modifier removed from 00813 | gi_00813_pt_stripped | INFORMATIONAL | 2 | The claim uses the combined GI endoscopy code 00813, and the autocoder removed the PT modifier because the payer is not on your exception list. No action is needed in the usual case. |
| Alert | Alert id | Type | Sev | When it fires and what to verify |
|---|---|---|---|---|
| Anesthesia line item has no times | anes_time_no_times | HARDSTOP | 10 | A time-billed anesthesia line has no start or stop time. Time-based billing cannot calculate units. Find the times in the anesthesia record and enter them. |
| Anesthesia type documented but no times found | anes_type_no_time_ranges | HARDSTOP | 10 | The note documents an anesthesia type, but the claim carries no anesthesia time range. Locate the start and stop times in the anesthesia record. |
| Anesthesia time exceeds 24 hours | anes_time_exceeds_24_hours | HARDSTOP | 8 | The calculated duration is more than 24 hours. Verify the times. If the case truly ran that long, confirm the record supports it. |
| Time overlap between procedures | concurrent_time_overlap | FINANCIAL | 7 | Two time-billed procedures have overlapping time ranges. Decide whether the procedures truly overlapped, or whether one belongs in the non-billable list. |
| Anesthesia times from handwritten notes only | handwritten_time_source | HARDSTOP | 5 | The times came only from handwritten documents, with no typed source to confirm them. Compare the extracted times against the handwritten record. |
| End time estimated from case events | anes_end_time_fallback_used | INFORMATIONAL | 1 | The autocoder found no explicit anesthesia end time, so it used a case event such as extubation. Confirm the estimated end time is reasonable. |
These alerts come from your facility's procedure billing rules. Your facility configuration controls each one. Contact your Hank representative to change it.
| Alert | Alert id | Type | Sev | When it fires and what to verify |
|---|---|---|---|---|
| Ultrasound 76937 image storage not documented | ultrasound_76937_no_storage_documented | COMPLIANCE | 7 | Ultrasound-guided vascular access was performed, but the note does not mention stored images. Check PACS for the images. |
| Ultrasound 76942 image storage not documented | ultrasound_76942_no_storage_documented | COMPLIANCE | 7 | Ultrasound guidance for needle placement was performed, but the note does not mention stored images. Check PACS for the images. |
| OB case review required | ob_case_review | HARDSTOP | 2 | The primary anesthesia code is an obstetric code (01958-01969). See OB Case Review Alert for the full check list. |
| Neuraxial procedure without times | neuraxial_without_times | INFORMATIONAL (configurable) | 4 (configurable) | An epidural or spinal was coded with no procedure times. Decide whether the service bills as time or as a flat fee. Add the times if it bills as time. |
| Qualifying-circumstance add-on coded | qc_addon_review | FINANCIAL | 5 | The claim bills 99116 or 99135. Verify the record documents deliberate hypothermia or controlled hypotension as an intentional technique. Confirm the payer pays the add-on separately. |
| Date of service over 1 year old | anes_dos_age_warning | HARDSTOP | 10 | The date of service is more than one year in the past. Verify the date is correct. |
| Post-op pain block documentation missing | postop_block_doc_evidence_missing | COMPLIANCE | 7 | A nerve block for post-operative pain bills as a separate flat fee, and the payer requires documentation the record scan could not find. The alert names the payer and the missing elements. Locate them in the orders, consents, or consult notes. |
| Alert | Alert id | Type | Sev | When it fires and what to verify |
|---|---|---|---|---|
| No anesthesia CPT code found | anes_no_cpt_code | HARDSTOP | 10 | The autocoder could not determine an anesthesia code for the case. Review the surgical procedure and assign the correct anesthesia code. |
| No anesthesia line item in final claim | no_primary_anes_line_item | HARDSTOP | 10 | The finished claim carries no anesthesia line. This catches cases where a line was produced and then removed by later cleanup. Confirm from the record whether the case should bill anesthesia. Labor epidural 01967 counts as a valid anesthesia line. |
| Primary diagnosis not attested | primary_icd_not_attested | HARDSTOP | 7 | The primary diagnosis is not stated in the record as the reason for the procedure. The alert names the source it came from. Open the chart and confirm a note attests the diagnosis. Do not bill on a problem list or history entry alone. |
| Planned procedure not coded | planned_procedure_missing_line_item | FINANCIAL | 8 | The record mentions a planned procedure, such as a nerve block or central line, but no matching code is on the claim. Decide whether the procedure was performed, then add the code. |
| Medicare qualifying circumstances not billed | medicare_qualifying_circumstances_bundled | INFORMATIONAL | 1 | The payer is Medicare, and the autocoder moved the qualifying-circumstance add-ons (99100, 99116, 99135, 99140) to the non-billable list. Medicare bundles them into the base anesthesia code. This is the expected behavior. |
| Extreme-age add-on 99100 not billed | extreme_age_99100_not_qualified | FINANCIAL | 5 | The patient's age on the date of service does not meet the extreme-age criteria, so the autocoder moved 99100 to the non-billable list. Confirm the date of birth and the date of service. |
| Upper and lower GI codes combined to 00813 | gi_codes_combined_00813 | INFORMATIONAL | 2 | The case documented both an upper endoscopy (00731) and a lower endoscopy (00811 or 00812), so the autocoder combined them into 00813. Confirm both procedures were performed. |
| OB add-on code without 01967 primary | ob_addon_without_primary | HARDSTOP | 9 | The claim bills 01968 or 01969 with no 01967 primary line. An add-on cannot bill alone. Add the 01967 line, or recode the case with the standalone cesarean code. |
| Surgical code has no anesthesia crosswalk | anes_crosswalk_gap_review | FINANCIAL | 6 | A surgical code on the case has no billable anesthesia code mapped to it, and it may outweigh the mapped procedures. Compare the selected anesthesia code against the dominant documented procedure, then check the base units. |
| Alert | Alert id | Type | Sev | When it fires and what to verify |
|---|---|---|---|---|
| Line item segmented for relief or handover | relief_line_segmented | INFORMATIONAL | 2 | A provider change happened during the case, so the autocoder split the anesthesia line into one segment per attending. Check the splits against the documented handover times. |
An acute pain service round is a visit made on a day after surgery to manage the patient's post-operative pain. Customers often send the whole record for these visits, which includes the original surgery documentation. The autocoder codes the round visit, not the surgery.
| Alert | Alert id | Type | Sev | When it fires and what to verify |
|---|---|---|---|---|
| Post-op pain rounds review gate | postop_pain_rounds_review_gate | HARDSTOP | 7 | Your facility enabled the pain-rounds review gate. The alert appears on every claim the pain-rounds lane coded. Compare the coded service against the round documentation. |
| Possible pain-round packet coded as surgery | postop_pain_round_ambiguous | HARDSTOP | 10 | The packet carries some pain-round signals, but not enough to route it as a round, so it coded as a normal anesthesia encounter. Decide which encounter the packet represents. |
| No billable pain-round service | postop_pain_round_not_billable | HARDSTOP | 8 | The record does not support a separately billable round. The alert names the exact criterion that failed. Read the criterion, then obtain an addendum if the documentation was unclear. |
| Surgeon transfer of pain management not documented | postop_pain_round_transfer_undocumented | COMPLIANCE | 7 | The record does not document the surgeon's request or transfer of post-operative pain management. Confirm a documented request exists. |
Two more families fire on anesthesia cases and on every other specialty. Patient and claim information alerts fire when the date of service, the patient name, the insurance, or a provider NPI is missing or invalid. Coding confidence alerts fire when the autocoder is less than 80 percent sure about a surgical code, an anesthesia code, a diagnosis, or a modifier. They behave the same way on every specialty; ask your Hank representative for the full catalog of shared alerts.
What happens next depends on how your organization consumes HANK CODES. In HANK Claim Maker, a HARDSTOP alert places the claim in the review queue your administrators configured for it. Organizations that consume the coding API directly decide in their own workflow which alerts pause a claim, who reviews them, and when a claim is released.