Anesthesia coding billing guidelines

jacobsl

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Can anyone help me with this question? I code anesthesia for a Boston hospital and I am fairly new at this. I am being told that I don't need an op note to do my coding. I was told that because it is "only anesthesia" I can just take whatever the OR schedule states as the procedure. My problem is that the OR schedule doesn't give diagnosis codes and the procedure listed is not always accurate. Can anyone tell me if there is a specific policy on this?
Lynda
 

LaSeille

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Are you coding for a billing company that does the anesthesia coding for a group of anesthesiologists at this hospital, or are the anesthesiologists employees of the hospital and the hospital itself does the billing for the anesthesiologists?

No, you do not have to code from an OP report. However, your fear about coding from the OR schedule is justified. I would be very suspicious of being told to code from the OR schedule....especially if it is the pre-operative schedule.

What about cases that are not on the schedule (ie: emergencies)? What about cases that start out as a simple exploratory procedure and end up as a very extensive surgery? Suppose the anesthesiologists provides an A-line...how would you know to bill for this? What if the surgery was started and then discontinued due to some unforseen circumstance? How would you know if a Medicare patient had MAC anesthesia and if you need to apply the QS modifier and a justifying diagnosis code? What about physical status modifiers?

I don't know. Something doesn't sound kosher. Have you been provided with any written guidelines on coding? What documentation will be provided to an auditor should the anesthesiologists get audited for their coding/billing? Who will be the responsible party that gets blamed for incorrect coding?

Do these anesthesiologists use any type of superbills? Can you code from the anesthesia record?

I would certainly be on my guard and checking this out further. Does anyone else out there have any advice for Lynda?
 
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