Wiki Anesthesia documentation

[LisaPayne]

I am taking on an anesthesiologist as a client and am not familiar with what documentation I should receive form him to accurately code. Obviously the Anesthesia record and patient info but is it customary to also get the operative report from the surgeon?

 

[irican]

Hello,

the documentation you need in order to code for anesthesia services is the following:
-pre-anesthesia record (this is where the comorbidities are documented that you need to support the need for MAC)
-anesthesia report
-post-anesthesia record
-surgeon's operative report (this ensures proper crosswalk selection of codes)

Here is additional information that great help in coding for anesthesia:

https://www.asahq.org/standards-and-guidelines/statement-on-documentation-of-anesthesia-care

https://www.asahq.org/standards-and-guidelines

http://static.aapc.com/a3c7c3fe-6fa...224e/d8a4f0fd-938b-458d-a1cd-0f1e2966e6d6.pdf

Good luck.

Ioana