Wiki Operative/Procedure Reports documentation requirements - HELP

[medlcg79]

I noticed on one of my providers procedure notes that there would be conflicting information. In the reason for appointment it would state : TFESI (NO SEDATION), but listed next to Anesthesia it would state "local and IV sedation". I queried him on in and he stated to go by what is listed in the reason for appointment (templates are used and it was not being updated). I informed him that the area of anesthesia would need to be updated as well. He is now removing this section in it's entirety if it is local sedation (if we are not billing for it). I queried him about it today and he asked if it was really necessary since the information is in the body of the note the medication administered and quantity given. I provided the physicians with the document "Dissect an Operative Report" last month. I reminded him of this and now he is asking the following:

Provider: "do we need to routinely document type of anesthesia if it is documented on the pacu record (with meds given)?"

Me: "Yes. It is part of the documentation required on the Operative Report. In the email I sent on 2/25/22, there was an attachment titled "Dissect an Operative Report". The 4th bullet under "The Heading of an Operative Report containes:" has "type of anesthesia" listed."

Provider: "I see that - is it a requirement or something that is good to have? If we are not billing for the anesthesia, I am trying to continue to use templates and simply omit the anesthesia type. If the patient receives IV sedation that is not being billed for, then the medications are charted as part of the pacu record"

Please help in how I should respond.

 

[elysia.york]

While I agree with you that the providers documentation does need to match from one area of the OP note to the next, I also believe that if you are not billing for the anesthesia, then there is no reason to go into detail in that section. My providers only document that type of anesthetic used - Local, General, etc.

If you reference back to the article that you provided your physician, you will see that all it mentions is "type of anesthesia; name of anesthesiologist/CRNA". While this information is not REQUIRED, it is best practice to have it in the OP note!

"Surgery Information – Name of the primary surgeon, co-surgeons, residents, and/or surgical assistants; type of anesthesia; name of anesthesiologist/CRNA; use of special equipment (microscope, robotics, etc.) and/or implants; complications; and estimated blood loss."
https://www.aapc.com/blog/49512-dissect-an-operative-report/

Hope this helps!