Results 1 to 4 of 4

Documentation Required for billing Anesthesia?

  1. Question Documentation Required for billing Anesthesia?
    Medical Coding Books
    In order to bill for anesthesia, do I need all 3 documentations- pre-op note,
    intra-op note (start-end time) and post-op note for Anestheologist or CRNA?
    If post-op note is not documented, can I still bill for 00XXX series?

    thanks in advance,

  2. #2
    I would think that your facility/facilities can clarify this for you. They have to meet the CMS documentation guidlines therefore they pass those requirements onto the providers that they have issued privileges to practice within their facility. We re-vamped our anesthesia forms a couple years ago and had to go through a "Forms Committee" at the facility for approval as the anesthesia records are part of the permanent hospital medical record.

    It would be necessary to complete a pre-anesthesia and intra-operative record, at a minimum, in order to meet the requirements for base units and capture information necessary for billing. As far as the post-op note, documentation of an anesthesia postop round is required by Joint Commission for accreditation. I have attached the CMS 341 has some minimum documentation requirements.

    So I don't have a definite answer but, I hope, at least pointed you in the right direction.

    Julie, CPC
    Last edited by jdrueppel; 12-18-2008 at 08:32 PM.

  3. Talking Anesthesia forms
    Would you be willing to share the form you created? I dont want to reinvent the wheel, so to speak, if I dont have to. We currently have an anesthesia record but I dont think its very user friendly. I would like to see what other facilities are using.


  4. #4

    Let me check with my administrator. I don't think it will be a problem but you know what happens when you assume.....
    Send me a private message with your contact info/fax number.

    Julie, CPC

Similar Threads

  1. 92579 - what documentation is required?
    By tkermode in forum ENT/Otolaryngology
    Replies: 1
    Last Post: 08-12-2014, 10:57 AM
  2. required documentation?
    By PLAIDMAN in forum Compliance General Discussion
    Replies: 3
    Last Post: 06-19-2011, 02:12 PM
  3. Antepartum visit required documentation
    By aces78rp in forum OB/GYN
    Replies: 0
    Last Post: 04-23-2010, 11:42 AM
  4. required MD documentation / lab tests
    By hunters in forum Pathology & Clinical Laboratory
    Replies: 0
    Last Post: 07-20-2009, 10:42 AM
  5. Documentation Required for 99232?
    By dhuston in forum E/M
    Replies: 4
    Last Post: 06-09-2009, 03:03 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.