Anesthesia Coding Alert

Question: Can you give me some guidelines on how long it should take an auditor to audit an anesthesia record?

Tennessee Subscriber

Answer: The time needed to complete an audit will depend on several factors, which may include:

• Use of paper versus electronic records
• Whether it’s an internal or external auditor
• The number of records reviewed

If your practice uses paper records, the audit usually takes longer, as the information is harder to read. An auditor from your office is more likely to be familiar with the handwriting, so their review may be quicker than that of an external auditor.

Internal auditors, someone within your organization, may choose to look at just one piece of the anesthesia record, such as medical direction criteria, or they may opt to review the entire record. Since they are internal, their pace may depend on when they have sufficient time to work on the internal review. Audit parameters also influence the time spent on the audit; the more information they review, the longer it will take.

External auditors, someone outside of your organization with anesthesia-specific experience, typically review the entire anesthesia record from processing to payment. This process can take anywhere from 15 to 30 minutes or more, depending on the circumstances, per record, according to experts. When they complete the audit, they should provide both a written report and resources to support any information provided within the report.

Tip: Your practice should have a compliance plan in place in which you outline audit details. If you have a compliance plan, it will dictate how often you perform internal and external audits, so plan accordingly.