# Documentation Required for billing Anesthesia?



## mvachon (Dec 18, 2008)

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,
mvachon


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## jdrueppel (Dec 18, 2008)

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.

http://www.cms.hhs.gov/manuals/Downloads/som107ap_a_hospitals.pdf

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

Julie, CPC


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## KBROWN77 (Mar 4, 2009)

*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.

Thanks,
Kelly


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## jdrueppel (Mar 4, 2009)

KJETT,

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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