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Thread: Documentation Required for billing Anesthesia?

  1. #1

    Question Documentation Required for billing Anesthesia?

    AAPC: Back to School
    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
    Join Date
    Apr 2007
    Lincoln, NE


    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 guidelines....page 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. #3
    Join Date
    Apr 2007

    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.

    Kelly Jett CPC,CCS

  4. #4
    Join Date
    Apr 2007
    Lincoln, NE



    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

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