Anesthesia Coding Alert

Rely on physician, not notes, to verify type of anesthesia

Before coding a case as MAC (monitored anesthesia care), be sure you're up to speed on the latest guidelines. Here's how to know whether you're reporting things correctly.
 
In October 2003, the American Society of Anesthesiologists (ASA) revised its statement on MAC to say, "If the patient loses consciousness and the ability to respond purposefully, the anesthesia care is a general anesthetic, irrespective of whether airway instrumentation is required."
 
Before coding for cases that involve unusual anesthesia - such as pediatric anesthesia during an MRI - verify that the physician administered MAC instead of general anesthesia. "A billing person doesn't know this by looking at the record," says Joanne Mehmert, CPC, of Joanne Mehmert & Associates  LLC in Kansas City, Mo., "so you need to verify it with the doctor."
 
If, after asking, you find that the record is wrong, have the anesthesiologist correct the record (mark one line through the word "MAC" and document the time and date of the new information). This ensures accuracy if you're ever audited.
 
The physician or CRNA might mark "MAC" on the chart when, under the ASA's revised MAC statement, the patient was unable to respond purposefully and did lose consciousness - which qualifies as general anesthesia. Because of this, always stress the importance of physicians and CRNAs getting the most accurate description of the type of anesthesia to you to help with coding.