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Anesthesia Coding Alert

Documentation Strategies:

Clue In to Medical Direction, Physical Status for Improved Claims Results

Published on Sun May 13, 2012

Add these 4 items to your ‘don’t miss’ list when checking procedure notes. Some of the smallest details tucked into a patient’s anesthesia and surgical records can make a big difference in how you code the case. You won’t find everything you need on the charge ticket " dig deeper into the procedure records themselves for items that can bump up your bottom line, such as medical direction, physical status, and more. 1. Clue In to Medical Direction Status One vital piece to your anesthesia coding is documentation supporting the provider’s role in the case. Did the physician personally perform the anesthesia service? Then be sure to append modifier AA (Anesthesia services performed personally by anesthesiologist) to the anesthesia code. If the anesthesiologist is involved by medical direction, choose either modifier QY (Medical direction of one certified registered nurse anesthetist [CRNA] by an anesthesiologist) or QK (Medical direction of two, [...]
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