Anesthesia Coding Alert

With so many requirements related to anesthesia documentation, its no wonder patient records dont always include the necessary information. But by educating anesthesia providers about what documentation is required, coders can make their job easier while helping providers achieve the most appropriate reimbursement for their services.

Documentation requirements can be grouped into two areas: (1) those items mandated by insurers or other regulatory bodies, and (2) those items that may not be necessary but that can ease the work of coding staff and improve your chances of receiving adequate reimbursement.

Code to Meet Insurer Requirements

A couple of years ago, we hired consultants to visit our company, go through all our policies and procedures, and give us all the corrections we needed to make to become a Medicare-compliant billing office, says Robin Fuqua, CPIC, a certified insurance coder with the medical group Anesthesia Consultants of California in Escondido. Because Medicare is the strictest of all insurers, we felt that if we can satisfy its requirements we should be doing well enough for other carriers.

Common requirements from insurers can include:

Notes from the patients preoperative evaluation and postoperative visit;

Accurate times documenting the procedure;

Vital signs and documentation of administering and monitoring drugs;

Anesthesia personnel involved in the procedure;

Type of surgery performed and anesthesia administered; and,

Patient consent to anesthesia.

Following the consultants visit, Fuquas office made a number of changes to ensure that its documentation was more likely to comply with insurer requirements:

All physicians must account for their time on the anesthesia record. Insurers may assume that the anesthesiologist did nothing if there are no indications of checking on a patients vital signs throughout a procedure.

Physicians must circle notations in the anesthesia record of any lines placed and charged.

Any pre-existing condition (such as a history of myocardial infarction or cancer) making the procedure riskier or warranting an emergency charge must be documented in the remarks section of the anesthesia record or in the description line of the groups charge sheet. Emergency situations that need to be documented can include hemorrhage, sepsis, vascular compromise, a ruptured appendix or other unanticipated circumstances.

Allow a maximum of seven minutes between the time a patient enters the post anesthesia care unit and anesthesia is discontinued, so the anesthesiologists stop time is easily documented. The only exceptions are for services assigned 13 or more base units (such as major lung, back or heart surgery) or when special circumstances require the anesthesiologist to write a short description on the anesthesia record or charge sheet. The physicians description is then summarized on the HCFA 1500 form for the insurance company.

Update computer databases to reflect changes to the base unit values [...]