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Anesthesia Coding Alert

Reader Questions:

Clearly Document CVP, PAC Catheters

Published on Wed Nov 17, 2010

Question: Our anesthesiologist wrote, "Seldinger technique left IJ 1st attempt" and then "PAC" on his chart. Is that enough documentation to stand up to an audit? If not, what documentation do we need from the anesthesiologist to support coding for CVP or PAC catheters?Answer: You must be able to determine several factors from the documentation before coding the case.What is the patient's condition? If the patient has an underlying cardiovascular disease or there is an anticipation of fluid or blood loss during the surgery, they may require an increased level of monitoring.Who provided the service? If the procedure was personally performed by an anesthesiologist, the answer is clear. However, if an SRNA, CRNA, Anesthesia Assistant or resident is involved in the case, handwriting alone is not sufficient for an auditor to determine who performed the service.What service was provided and when? When a pulmonary artery catheter (PAC) is placed, the [...]
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