Anesthesia Coding Alert

Question: Is there anything in writing somewhere that specifically mandates what an anesthesiologist must do as part of a patients pre-op exam?

Wisconsin Subscriber

Answer: The American Society of Anesthesiologists (ASA) has established basic standards for preanesthesia care. These standards apply to all patients who receive anesthesia or monitored anesthesia care (MAC), but may be modified under unusual circumstances. The circumstances surrounding these special cases must be clearly documented in the patients record. The standards outline that an anesthesiologist shall be responsible for determining the patients medical status, developing an anesthesia care plan and acquainting the patient or the responsible adult with the proposed plan.

The development of an appropriate plan includes several steps. These are:

reviewing the patients medical record

interviewing and examining the patient to discuss his or her medical history, previous anesthetic experiences and drug therapy, and to assess aspects of the patients physical condition that might affect decisions related to his or her anesthesia risk and management

obtaining and/or reviewing tests and consultations necessary to the conduct of anesthesia

determining the appropriate prescription of preoperative medications as necessary.

The responsible anesthesiologist must verify that these steps have been properly taken and documented in the patients medical record.

ASA also has a published statement regarding routine preoperative lab and diagnostic tests. It reads, Preanesthetic laboratory and diagnostic testing is often essential; however, no routine laboratory or diagnostic screening test is necessary for the preanesthetic evaluation of patients. Anesthesiologists, anesthesiology departments or healthcare facilities should develop appropriate guidelines for preanesthetic screening tests in selected populations after considering the probable contribution of each test to patient outcome. Individual anesthesiologists should order test(s) when, in their judgment, the results may influence decisions regarding risks and management of the anesthesia and surgery.

The statement also says that legal requirements for lab testing should be followed, that test results relevant to anesthesia management should be reviewed prior to initiation of the anesthetic, and relevant abnormalities should be noted and action taken as appropriate.

The complete text for these standards and others can be found on ASAs Web site: www.asahq.org/standards. You can also call ASAs office at (847) 825-5586 for more information.