Wiki Compliant Med Direction Documentation

[lschock79]

Due to Medicare's vague descriptions of emergence (due to it being considered a continuum) I am having a hard time finding information on when emergence for medical direction should be documented/signed. Currently at my hospital present at emergence has been documented in the line by line activity section of the anesthesia report/record, however due to tight schedule our head of anesthesiology is asking that it be placed in the post op document (the PACU is currently being run by a separate anesthesiologist than is doing the time based portion of the case). Could there possible be concurrency issues with this? I realize once they are in the PACU it is outside of the realm of time based reporting, but if they are documenting the emergence and therefore including themselves in part of the medical direction continuum it seems to me that they still should be held to a "less that 5" policy even there. Is the documenting/signing of "present at emergence" even ethical in the PACU just to be able to bill at the higher med direction rate? I have done so much research on this and just have found very little. Turning it over to my fellow coding professionals to see if they have advice/regulations they can share that I am missing somewhere.

 

[tec76]

Hi. In U.S. ex rel. Donegan v Anesthesia Associates of Kansas City (2016), the 8th Circuit Court of Appeals held that, “emergence…includes the patient’s continued recovery in the PACU…” So, yes, documenting “present at emergence” in the PACU is perfectly fine.

 

[lschock79]

Hi. In U.S. ex rel. Donegan v Anesthesia Associates of Kansas City (2016), the 8th Circuit Court of Appeals held that, “emergence…includes the patient’s continued recovery in the PACU…” So, yes, documenting “present at emergence” in the PACU is perfectly fine.

Yes I had already read this and was a little disappointed: thrown out due to Medicare's own vagueness and lack of definition. However it did open my eyes to see that even CRNAs practicing under this model felt it to be a little less than ethical still billing it at the med direction rate.