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Documentation for post-op pain management

  1. #1
    Smile Documentation for post-op pain management
    Medical Coding Books
    I was wondering if anyone could help me out on what is exactly needed as far as documentation goes, from the surgeon when a anesthesiologists performs a procedure for post-op pain. I am aware that the surgeon has to request in their documentation that anesthesia performs a prodedure for post-op. But what all exactly does the surgeon have to include?

    Also I am aware that as long as the anesthesiologist documents that the procedure was done for post-op pain and as long as the procedure IS NOT used as the same route for the anesthesia for the surgery, then we can code those seperately. (of course it has been requested by the surgeon) Please correct me if I am wrong! Thank you in advance for your help.

    Also any suggestions on resources whether the be online or book are greatly appreciated.

  2. #2
    I think the info you need would be in the ASA RVU book. The circumstance you described in your post is exactly what you need. You will need to use the postop pain code .. I am at home and dont have a book but I think it is 338.18.. you will need to append -59 to your injection code otherwise you will probably have to appeal all of them and these injections are billed type of svc 2 not 7. For some reason insurance carriers do not realize the types of svc are diff or the dx code or the contact me if you need addl info

  3. #3
    Thanks for your help!

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