Wiki coding based off CRNA documentation

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jsz123

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Can coding pull in dxs from the CRNAs preop exam to justify the higher level physical status modifier to the payer? (the comorbidities are not documented in the surgeon's H&P or OP report). Any guidance is appreciated.
 
All anesthesia providers are supposed to do a pre-op H&P that is recorded on the anesthesia record. That H&P is what's used to determine the Physical Status score (P1-P6). So, yes, the anesthesia record is used to determine the ASA score.

Often times, the surgeon will not document co-morbidity diagnoses that appear to be irrelevant to the case, however those diagnoses are important to the anesthesia service. The surgeon's documentation demonstrates why the anesthesia service was necessary, and the anesthesia record should contain documentation proving the medical necessity for the level of anesthesia service provided.
 
LisaAlonso23 said:
All anesthesia providers are supposed to do a pre-op H&P that is recorded on the anesthesia record. That H&P is what's used to determine the Physical Status score (P1-P6). So, yes, the anesthesia record is used to determine the ASA score.

Often times, the surgeon will not document co-morbidity diagnoses that appear to be irrelevant to the case, however those diagnoses are important to the anesthesia service. The surgeon's documentation demonstrates why the anesthesia service was necessary, and the anesthesia record should contain documentation proving the medical necessity for the level of anesthesia service provided.
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Thank you for your reply Lisa. Great information!
 
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