Anesthesia Coding Alert

Question: Does Medicare have specific requirements regarding how the anesthesiologist describes the procedure in the anesthesia record? Some of our physicians say the actual anesthesia descriptor for the procedure should be in the record (such as "Anesthesia for procedures on lower posterior abdominal wall" for 00820). How specific does the anesthesiologist's documentation need to be?

Kentucky Subscriber

Answer: Your physicians might be thinking that writing verbatim CPT descriptors in their charts will eliminate the need for using the Crosswalk and cut down on mismatching the surgical and anesthesia codes. This may seem logical, but it isn't necessary. Medicare does not use the Crosswalk and does not match the surgeon's CPT code with the anesthesiologist's code before making payment, so including the anesthesia descriptor in the record doesn't make much difference.

Instead, begin by looking for information about the actual surgical procedure performed. This gives you much more precise information about the procedure, especially if you can access the operative report. That information and the Crosswalk usually help make it clear what anesthesia code you'll report (and what supporting diagnoses apply), so the anesthesia provider does not need to include verbatim descriptions of CPT codes in his notes. When in doubt, call the surgeon's office to get more details on the case for correct coding.