Any guidance regarding this issue Clinician writing DX Code instead of descriptive text on the anesthesia records. Would you count this as an error on the audit and educate the clinician to write a descriptive text?
Good point Lisa. I wonder, if the anesthesia record is housed within a shared record such as the hosital record, could that be used? Could it be pulled from an operative report provided the anesthesia provider has access? I am guessing probably not and many practices have access issues I'm sure. If they are only provided with a code, they could at least convert that code to words and dictate that instead, couldn't they?I've been coding anesthesia for over 8 years. Please know that most often anesthesia providers have a difficult time obtaining diagnosis information. I've spoken with a lot of anesthesiologists and CRNAs to gain knowledge about their processes while on a case, so that I could have realistic expectations. Many told me they get what they get. Often times they're only provided with a code.
That said, talk to your providers to see if it's possible for them to get the diagnosis as opposed to the code.
The anesthesia record is recorded in real time and then they are gathered at each facility to transport to their billing office. However, Op notes are completed well after the procedure and are not available immediately for the anesthesia providers to extract information from.Good point Lisa. I wonder, if the anesthesia record is housed within a shared record such as the hosital record, could that be used? Could it be pulled from an operative report provided the anesthesia provider has access? I am guessing probably not and many practices have access issues I'm sure. If they are only provided with a code, they could at least convert that code to words and dictate that instead, couldn't they?