Advanced Search

Revenue Cycle Insider

Anesthesia Coding:

Beware These Top Anesthesia Documentation Deficiencies Found in Audits

Published on Thu Oct 29, 2026

You’ve reached your limit of free articles. Already a subscriber? Log in.

Not a subscriber? Subscribe today to continue reading this article. Plus, you’ll get:

Simple explanations of current healthcare regulations and payer programs
Real-world reporting scenarios solved by our expert coders
Industry news, such as MAC and RAC activities, the OIG Work Plan, and CERT reports
Instant access to every article ever published in Revenue Cycle Insider
6 annual AAPC-approved CEUs
The latest updates for CPT®, ICD-10-CM, HCPCS Level II, NCCI edits, modifiers, compliance, technology, practice management, and more

Other Articles of

October 2026

Optometry/Ophthalmology Coding:
Pin Down the Retinitis Pigmentosa Diagnosis
Distinguish the retinal disorder, associated syndromes, and visual impairment to tell the complete coding story. [...]

Optometry/Ophthalmology Coding:
Use 7th Characters to Identify POAG Stages
Question: Our ophthalmologist diagnosed a patient with primary open-angle glaucoma (POAG), but the right eye [...]

Gastroenterology Coding:
Back up Paracentesis and Percutaneous Liver Biopsy Codes With Accurate Documentation
Find out how to tell if imaging is guidance or incidental. Gastroenterology coding as it [...]

Urology Coding:
Know How to Code a Case When a Difficult Foley Becomes a Cystoscopy
Follow the instruments, anatomy, and documentation to avoid bundling issues. A routine Foley catheter insertion [...]

Anesthesia Coding:
Beware These Top Anesthesia Documentation Deficiencies Found in Audits
Dot your i's and cross your t’s to shore up your records. Complete and correct [...]

Podiatry Coding:
Code Arthroscopic and Debridement of Talar Osteochondral Lesions, Part 1
Learn how similar procedures are reported differently. An ankle arthroscopy operative report may describe excision [...]

Path/Lab Coding:
Beware These Per Diem Service Lab Test Bundles
Question: We are an independent laboratory that has been experiencing denials for our toxicology services [...]

Optometry/Ophthalmology Coding:
Should You Report 92133 and 92134 for OCT of the Optic Nerve and Retina?
Question: Our ophthalmologist ordered and performed optical coherence tomography (OCT) of the optic nerve and [...]

Podiatry Coding:
Know How to Recognize Class Findings for Nail Debridement Reimbursement
Question: A 78-year-old Medicare patient with type 2 diabetes and peripheral angiopathy presented to the [...]

Pulmonology Coding:
Build a Home Oxygen Record That Survives a Documentation Request
Plus, get to know the different qualification criteria. Home oxygen therapy remains one of the [...]

Technology & Innovation in Healthcare:
Face the Reality of 5 Ambient AI Documentation Myths
Who is ultimately responsible for the AI’s output? Ambient artificial intelligence (AI) is a helpful [...]

Anesthesia Coding:
Find Clarity on When to Use Unlisted Procedure Code
Question: When is it appropriate to report CPT® code 64450 versus 64999? Codify Subscriber Answer: [...]

In Case You Missed It (RCI Bonus Content):
Medicare Tests ACCESS to Improve Chronic Care Through Technology
Understand this payment alternative for your chronically ill Medicare patients. On July 5,2026, Medicare began [...]

General Surgery Coding:
Identify an RS&I Code for Intraoperative Cholangiography
Question: During a laparoscopic cholecystectomy, the surgeon performed an intraoperative cholangiogram due to the patient’s [...]

General Surgery Coding:
Is an Appendectomy Considered Incidental if the Appendix Was Normal?
Question: A patient presented with intermittent right lower quadrant (RLQ) pain, mild nausea, and a [...]

Oncology/Hematology Coding:
Don’t Automatically Assign a High E/M COPA Level for Cancer Dx
Question: A patient with stage IV colon cancer presents for a follow-up, and the provider [...]

Podiatry Coding:
Pay Attention to Wound Depth When Coding Debridement Procedures
Question: A patient presented to the podiatrist with a venous-related ulcer on the left dorsal [...]

Pediatric Coding:
Quiz Yourself on These Common Breathing Issues
Accurate respiratory coding depends heavily on provider documentation. Can you tell the difference between acute [...]

Primary Care Coding:
Use These Tips to Boost Primary Care Assessment Documentation
Reframing documentation as part of clinical care can positively impact everyone. There are three pillars [...]

Ob-Gyn Coding:
Recognize How to Report Subdermal Contraceptive Removal and Reinsertion
Question: A 28-year-old patient presented to their gynecologist for removal and replacement of a nonbiodegradable [...]

Medicare Regulations:
Code Shingles Vaccine Separately From Medicare AWV
Question: A Medicare beneficiary presents for a subsequent annual wellness visit (AWV) and asks to [...]

Diagnostic Radiology Coding:
Code This Screening-Turned-Diagnostic Mammography Medicare Case
Question: A Medicare patient with no history of breast cancer presented for their annual screening [...]

Compliance:
See Encounter Templates as a Blank Page
Question: Our behavioral health practice uses templates for psychotherapy notes. During an internal audit, we [...]

Neurosurgery Coding:
Code All Services Correctly on TDA Revision/Replacement Coding, Part 1
Check with payer for conservative therapies they might require before surgery. To determine if a [...]

Neurosurgery Coding:
Age May Not Be the Only Difference Between Early-, Late-Onset Alzheimer’s
Question: What is the difference between early- and late-onset Alzheimer’s disease, and what are the [...]

Otolaryngology Coding:
Get the Answers to All Your Ethmoidectomy Questions
Know how to use ethmoidectomy combo codes correctly. You know that when medical interventions such [...]

Diagnostic Radiology Coding:
Count the Views — Not the Images — to Bill X-Rays Correctly
Question: A patient presented to urgent care with a fever of 101.2 degrees Fahrenheit (F), [...]

General Coding:
Better Capture CCM to Get Paid for the Work
A workflow adjustment can pull in the chronic care management revenue practices already earn. Independent [...]

Diagnostic Radiology Coding:
Recognize Accurate 3D Rendering Documentation to Report 76376 and 76377
Find out which procedures include 3D rendering. The 3D rendering CPT® codes took effect Jan. [...]

Practice Management:
Build a Measles Response Plan Around Airborne Precautions
Question: Public health officials have confirmed community spread of measles in our region. Should our [...]

Emergency Department Coding:
Beware Bundled Services When Coding Inhalation Tx
Question: Encounter notes indicate that the emergency department (ED) physician performed therapeutic nonpressurized inhalation treatment [...]

E/M Coding:
Assess Risk With Confidence on Your E/M Claims
Learn why documentation matters when coding based on risk assessment. In this final installment of [...]

Ob-Gyn Coding:
Learn How to Report Pessary Device Supply
Question: A 68-year-old patient with stage 3 apical pelvic organ prolapse presented with pelvic pressure [...]

Cardiology Coding:
Code Infective Endocarditis Symptoms Unless Diagnosis Confirmed
Question: An established patient with a prosthetic aortic valve sees the cardiologist 10 days after [...]

Otolaryngology Coding:
Beware Bundling Cochlear Implants With These Procedures
Question: I could use some help in billing for cochlear implants, specifically what a complete [...]

General Surgery Coding:
Code Central Venous Access From Insertion Through Removal
Find out if guidewire use implies a catheter exchange. Central venous access coding depends on [...]

Orthopedic Coding:
Strengthen Documentation in Your Ortho Practice
By following these expert tips, you can help protect your office against denials. From overreported [...]

Practice Management:
Make Sure Each Patient in Family Is Registered for Their Group Flu-Shot Visit
Question: A family of five wants to come to our office together for influenza vaccinations. [...]

ICD-10-CM Coding:
Code the Residual Scar Before the Healed Burn
Question: A patient sustained a second-degree skin burn of the right forearm several years ago. [...]

Cardiology Coding:
Choose the Right Codes for an Initial Pectus Excavatum Evaluation
Question: A 16-year-old patient is referred to a cardiologist for an initial evaluation of pectus [...]

Technology & Innovation in Healthcare:
Understand What’s in the Healthcare Cybersecurity and Resiliency Act
Build better healthcare protection with this bipartisan bill. On Sept. 30, the U.S. Senate unanimously [...]

Path/Lab Coding:
Know Who Can, and Who Cannot, Bill for Lab Draws
Question: Our clinic laboratory draw station receives laboratory orders from an outside provider. The phlebotomist [...]

Neurology & Pain Management Coding:
Learn New Sleep Study Codes to Stay Sharp in 2027
Question: I know that CPT® 2027 will include new and revised codes for autonomic nerve [...]

Technology & Innovation in Healthcare:
Use AI to Approve and Renew Prescriptions
Question: We have several prescription renewal requests come in each week for patients with chronic [...]

Primary Care Coding:
Choose Initial Nursing Facility Care for a PCP’s First SNF Visit
Question: Our primary care physician (PCP) sees an established 79-year-old patient in the office for [...]

Urology Coding:
Don’t Overcode When a Combination Code Is a Better Choice
Question: A 61-year-old patient with recurrent nephrolithiasis presented to the urologist with acute left flank [...]

General Coding:
Look to a Modifier For This Unanticipated Skin-Tag Removal
Question: An established patient presents to a primary care office with worsening right knee pain [...]

ICD-10-CM Coding:
Don’t Mix up Brackets and Parentheses in ICD-10-CM Entries
Question: I’m new to coding and have noticed that both brackets and parentheses are used [...]

Gastroenterology Coding:
Know When Imaging Guidance Is Included
Question: I have a report for a paracentesis procedure performed on a 58-year-old patient. The [...]

Compliance:
Make Sure Dermatology Procedure Notes Support the Claim
Question: Our dermatologist evaluates a patient with several rough, scaly lesions on their face and [...]

Neurology & Pain Management Coding:
Nerve System Function Test Codes Get Major Overhaul in CPT® 2027
New code set makes test coding far more specific. The AMA has announced the final [...]

Otolaryngology Coding:
Understand Nasal Anatomy to Correctly Code This Closed Treatment Encounter
Question: The operative report states: “Asch forceps were used to medialize the septum from the [...]

Orthopedic Coding:
Understand Annular Defect Coding
Question: My provider documented an intervertebral annulus fibrosis defect in the lumbar region. I cannot [...]

Primary Care Coding:
Don’t Report a Suspected Intolerance
Question: A 42-year-old established patient returns to the primary care office for an in-person follow-up [...]

Pediatric Coding:
Get Full Credit for Independent Imaging Interpretations
Question: My pediatrician independently reviewed MRI images after the radiologist issued a report. Can that [...]

E/M Coding:
Justify a Higher E/M Level Based on Notes Alone
Question: Our practice sees many student athletes with sprains and other sports-related injuries. Even though [...]

General Coding:
Establish Your Procedure Coding Selection Workflow
Question: As a recently credentialed coder, I’m familiar with how to look up codes generally, [...]

Urology Coding:
Examine This Epididymitis Coding Case
Question: A patient presented to the urologist with complaints of pain while urinating, pain in [...]

Oncology/Hematology Coding:
Mend Your Misunderstanding of Multiple Myeloma Coding, Part 2
ICD-10-CM leaves questions about MM remission, personal history, relapse, and metastasis unanswered. Last month, we [...]

Oncology/Hematology Coding:
Code for Injection, Not Puncture, in This Intrathecal Chemo Scenario
Question: How would you code this note? Ommaya reservoir was accessed with a 25-gauge butterfly, [...]

Pediatric Coding:
Learn Key Terms for Accurate Otitis Media Coding
Question: I’m relatively new to coding. When my pediatrician diagnoses a patient using terms like, [...]

Emergency Department Coding:
Identify Incision to Slice Your FBR Coding Choices Down
Question: I have an operative report stating that the emergency department (ED) physician performed foreign [...]

Neurosurgery Coding:
Remember to Choose Different Codes for Array Implant With MER
Question: A 72-year-old patient reports with suspected essential tremor. Encounter notes indicate that the condition interferes [...]

E/M Coding:
Report Minor Procedures and Modifier 25 Correctly
Question: Do I need to append modifier 25 every time I report an evaluation and [...]

Neurology & Pain Management Coding:
Know Test Purpose to Differentiate PET, CT, MRI
Question: Our neurology practice performs positron emission tomographic (PET) scans, as well as CTs and [...]

Ob-Gyn Coding:
Learn How to Code Maternity Services That Bridge 2026 and 2027
Should you wait to code prenatal visits until December 31? The AMA has announced massive [...]

Anesthesia Coding:
Find the Right Code and Modifier for a Routine Screening Colonoscopy
Question: How do I code the anesthesia services involved for a 52-year-old healthy patient undergoing [...]

Gastroenterology Coding:
Understand What ‘Multiple’ Means in Descriptor for 43239
Question: If a gastroenterologist performs an esophagogastroduodenoscopy (EGD) with biopsies at multiple sites, does that [...]

Compliance:
When Screening Comes With a Bill: Navigating Supplemental Breast Imaging Coverage, Part 2
Thread the needle on your responsibility to patients — and compliance. Claim accuracy and patient [...]

Orthopedic Coding:
Choose the Right Codes for a Repeat Achilles Rupture
Question: The notes indicate that the patient previously ruptured their left Achilles tendon five years ago [...]

Medicare Regulations:
Fight Back Against Glucose Monitoring Supply Denials
Question: The Centers for Medicare & Medicaid Services (CMS) updated readers on the latest improper [...]

ICD-10-CM Coding:
Know the Guidelines for Reporting Chronic Conditions, Part 2
Dive deeper into exploring when stable chronic conditions belong on the claim. Coders may have [...]

Path/Lab Coding:
Know These 4 ‘Ps’ for Precision Drug Test Coding
Beware of Medicare’s definitive drug testing codes. Purpose, procedure, payer, and proof — align these [...]

Practice Management:
Design Effective, Ongoing Healthcare Compliance Training, Part 2
Hint: Prioritize sustainability in your approach. An effective and strong healthcare compliance curriculum is a [...]

View All

Subscribe to newsletter