Wiki How to code anesthesia when 2 procedures done

[lillianbarker]

Patient has Colonoscopy and EGD done, do I need the anesthesia time per procedure or do I code the main procedure and total units?

 

[Derry1]

I will suggest you code the come complex procedure among them. The actual/original documentation refers...

 

[CodingKing]

Code the procedure with the highest base units (or just pick one if its a tie) and then add up the total time.

 

[maryir]

I think it's the same question but with Moderate Sedation - same answer????

I didn't see this thread until I submitted my question - Is it the same question - I look at it as a documentation/compliance issue per procedure/service.

I have a GI physician who is charging for Moderate Sedation while performing two separate procedures, an EGD and a Colonoscopy. The Moderate Sedation is noted in one note (the Colonoscopy) describing the Moderate Sedation, which includes the time recorded for both the Colonoscopy and EGD.
The Dr is stating that he performed one procedure immediately after the other and that the documentation of the Moderate Sedation within the one note is sufficient.
I’m stating each note must be independent. That the Moderate Sedation should be noted in both notes.
Am I looking at this wrong?

 

[CodingKing]

I didn't see this thread until I submitted my question - Is it the same question - I look at it as a documentation/compliance issue per procedure/service.

I have a GI physician who is charging for Moderate Sedation while performing two separate procedures, an EGD and a Colonoscopy. The Moderate Sedation is noted in one note (the Colonoscopy) describing the Moderate Sedation, which includes the time recorded for both the Colonoscopy and EGD.
The Dr is stating that he performed one procedure immediately after the other and that the documentation of the Moderate Sedation within the one note is sufficient.
I’m stating each note must be independent. That the Moderate Sedation should be noted in both notes.
Am I looking at this wrong?

I don't know much about moderate sedation but i'm confused why 2 separate OP reports were done. I'm used to seeing only one OP note even if multiple procedures are performed in the same surgical session. I do believe both notes need to stand alone.

 

[maryir]

Do you know of a site when I could find the guideline stating both notes should stand alone? I've presented this to my management and they do not believe each procedure note requires complete/independent documentation. I believe they're looking at it from a facility standpoint and not pro.