Wiki Post operative DX?

[beachgrl62]

Hoping to get some input on this subject. A question has arose from our recent audit. The coder auditing has insisted that we add DX codes that occurred in the PACU to the anesthesia charges. I don't agree with that and hoping someone can shed some light on this. I have been coding for 10 years and have always used the DX codes the provider enters from the pre-op exam and also from the op note. Any codes from the PACU have been entered by a different provider. The claim in question had a DX of tachycardia in PACU AFTER the procedure. This was not assigned prior. Thoughts?? Thank you!

 

[lcole7465]

First, did the anesthesiologist already sign off the case in PACU when this accured? If he/she has and this documented by the nurse or another doctor then it would be part of their record, not the anesthesia record.

 

[beachgrl62]

First, did the anesthesiologist already sign off the case in PACU when this accured? If he/she has and this documented by the nurse or another doctor then it would be part of their record, not the anesthesia record.

Apparently the anesthesiologist had not signed off yet. This was a good lesson in documentation.

 

[lcole7465]

Apparently the anesthesiologist had not signed off yet. This was a good lesson in documentation.

If he has not signed off and released the patient from anesthesia care then this would be part of the anesthesia record, and I would consider using it only if the patient's PS is a 3 or higher.