Anesthesia Coding Alert

Hint: Pay special attention to throacoscopy, spine, and cardiac cases. Anesthesia coders automatically turn to their provider's notes and the anesthesia record for details regarding cases. But the surgeon's record can also contain information that can make or break your claim, such as case complexity or procedure changes. Dig Into the Case Complexity "There are two things we identify most often when comparing the anesthesia documentation to the operative note," says Cindy Hinton, CPC, CCP, CHCC, owner of Advanced Coding Solutions in Franklin, Tenn. "Number one is that we find that the procedure was more complex than expected." Example: The anesthesia record includes a notation of "knee arthroscopy." The operative note states that the surgeon completed debridement, repair, or reconstruction. Knowing that the surgeon performed something more than a diagnostic procedure can move you from reporting a code such as 01382 (Anesthesia for diagnostic arthroscopic procedures of knee joint) to [...]