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Wiki One lung ventilation documentation

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solocoder

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Does one lung ventilation have to be documented in the anesthesia note in order to use ASA 00541? Or is it enough that the surgeon documented it in their note?
Thanks.
 
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The op note is only used to code the diagnosis and procedure. The diagnosis justifies the procedure performed by the surgeon. The surgeon is only responsible for documenting his/her services. Although the surgeon may document one-lung ventilation due to it being anticipated, he/she does not perform this service. Therefore, it would not be appropriate to code an anesthesia service from the op note.

The anesthesia record documents the anesthesia service(s) provided and is the only resource for coding anesthesia services. That said, the anesthesia providers need to be documenting one-lung ventilation on the anesthesia record for 00541 to be coded.
 
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