Anesthesia Coding Alert

"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 provider might not include in his record, partly because the information doesn't impact the anesthesiologist, but also because the anesthesiologist might not know all the details of the case.

"If the anesthesia record is not sufficient, check the operative report if it's available," Arnett says. "Many times, the surgical report has more site-specific details than the anesthesia record. I often find myself changing a code based on information in the operative report."

Details available in the surgical report that the anesthesia provider may not note include:

"The simple things that the surgical record might include can be very important," Embich adds. "Even if those details help you change to an anesthesia code that's only one base unit higher, it's worth it."

Find More Details in Pathology Reports

Information in pathology reports can also help increase your coding accuracy, especially when the operative report mentions cancer.

"Pathology reports are crucial to anyone's coding," Embich says. "Don't assume anything, no matter what the operative report says. If the report mentions cancer, be sure it's a current diagnosis rather than past history -- miscoding something like that can ruin the patient's medical history with a carrier. I never code cancer unless I have a pathology report in hand."

Arnett agrees with this tactic, although she rarely uses pathology reports in her day-to-day coding. "I have access to them, but the operative report and/or anesthesia record seem to be adequate for our billing," she says.

If you don't have access to pathology reports to confirm cancer diagnoses, experts recommend that you report "unspecified" ICD-9 codes when you're coding neoplasms or lesions.

Embich and Arnett also have access to their hospitals' billing systems and patient medical records. "We sometimes check how the hospital coded the patient diagnosis and/or procedure," Arnett says, "especially if the op note is not available and the anesthesia record's information is insufficient."

Check Nurses' Notes

You should also review nurses' notes for complicated cases such as a motor vehicle accident (MVA), Embich says. ICD-9 does not include a specific code for MVA, so you should report the patient's injuries based on ICD-9 trauma codes.

"The nurses' records are quite accurate and can help when you're coding for a patient with head-to-toe injuries," she says.

Study Your Practitioners' Habits

Always pay attention to the coding habits of your physicians and other providers, Embich says. "The CRNAs I work with are predictable," she says. "I actually know who has the possibility of error and who doesn't. When I get a 'feeling' about a case, I pay close attention. Nine times out of 10 I'm right to question them and dig deeper before coding the case."

The following tips can help you garner the facts from your practitioners' reports: