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alk@APS

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What documentation do you use to code anesthesia cases? The docs I work for give me the Anesthesia Summary and it will have a diagnosis which doesn't always match the OP note. Also they may give me an ASA code of a 3 or 4 with no supporting diagnosis. I work in a hospital so I have access to OP notes and medical records can I use this to support the level even though the anesthesiologist did not provide the information? I'm trying to be as thorough as possible without crossing any lines and I am still very new to anesthesia coding so any advice is greatly appreciated.
 

andreljones

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Anesthesia

In my experience with Anesthesia billing...they seem to never provide anything other than summary sheet which will indicate dx, ASA level, stop and start times of anesthesia. Generally this is enough to bill the services. Anesthesia a different specialty than most. Services billed are piggybacked from the Surgeon. Having access to the OP report will help a lot. The key to getting paid is to make sure that codes correlates to Surgeon's billed codes.
 

aaron.lucas

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you could try asking for the actual anesthesia record, with the grid on it. that will sometimes show all the times that they are supposed to record, including when they're moved to the PACU. it's also a little more detailed than just the summary.
 
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