Anesthesia Coding Alert

Increase reimbursement by sifting through several sources -- not just the anesthesia record

Many coders only have access to their physicians' charts when it's time to submit a claim, but anesthesia coders are a different story. If you have access to the anesthesia record, the operative report, pathology reports and more, this wealth of information can help create a full picture from a coding perspective -- and it can help you locate hidden base units. But the accessibility can be a double-edged sword if you don't know where to find the best information. Our experts show you how to sift through the physicians' documentation to select the most important coding factors. Start With Anesthesia Record for Basics The anesthesia record is usually the best place for you to start when selecting a CPT code. You can usually find the following information in the anesthesia record:

Whether the physician inserted Swan-Ganz, arterial (A-line), or central venous pressure (CVP) lines, and for what purpose

 General information regarding the patient's diagnosis and procedure, as well as information on past or present health conditions that can affect the procedure (hypertension, past coronary or pulmonary problems, chronic disease, etc.)

 Documentation that supports anesthesia's medical necessity

 The type of anesthesia the physician or CRNA provided (general, local, MAC)

 Whether the anesthesiologist placed and/or used TEE (transesophageal electrocardiography) probes, fluoroscopy, BIS monitors or other devices that you can sometimes code separately

 Documentation supporting the physician's role regarding medical direction or supervision

 Exact times for anesthesia care, including documentation of hand-offs between members of the anesthesia team and which services each practitioner provided

 The patient's physical status (designated by modifiers P1-P6 and defined in CPT's anesthesia guidelines). "I start by reading the written diagnosis and procedure the physician includes on the charge form," says Kim Arnett, CPC, a coder with Georgia Anesthesiologists PC in Marietta. "Then I compare the charge form to the actual anesthesia record for accuracy. I also note the patient's physical status and condition, the patient's position during the procedure, any line insertions, and other details that can affect my coding."

You can also find helpful coding clues -- or "extra points" -- in the anesthesia record's "miscellaneous information" box, says Vicki Embich, a coder with West Florida Medical Clinic in Pensacola. "I've often found notes in this box stating the surgeon performed an off-pump CABG," she says. "Providing anesthesia for an off-pump procedure (without the pump oxygenator) versus an on-pump procedure (with the pump oxygenator) adds five  more base units to my charge." Dig Up Details in Op Reports After you glean the anesthesia record's important information, you should focus on the surgical (or operative) report. Surgeons often include details about the case that the anesthesia [...]