Yes, they are the same... Records vary a lot. As a coder when we are assigning the codes and modifiers we often do not have the 1st and 7th step because the record comes seperated or for the 7th step the provider has up to 48 hours to complete. Often, coders use a 3-5 day lag time so they are able to review the entire anesthesia record for the 7 steps. There are those situations when we never get that information. I often discover in my audits that step 7 is not documented or supported, resulting in broken medical direction. Discuss with your providers what you are looking for and what they may want to consider documenting with respect to the following;
"Evaluation cannot begin immediately upon arrival to the designated recovery area and cannot occur until after patient has sufficiently recovered from the effects of anesthesia so as to participate in the evaluation (e.g. answer questions and perform tasks)"
this statement was issued by the ASA... Audits bring a lot of things to lite, often things that the providers forget about as their focus is patient care not the dotting of i's or crossig t's
hope this helps.
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