Anesthesia Coding Alert

Reader Question:

Verify Local Policy for Medical Direction Sign-Offs

Question: I've reviewed Medicare guidelines for medical direction documentation, but our coders can't agree on one question. Does the anesthesiologist need to sign the anesthesia document along with the CRNA when he provides medical direction?  Iowa SubscriberAnswer: Different practices might handle this situation in different ways because Medicare doesn't provide specific guidelines. Two medical direction requirements are that the anesthesiologist complete -- and sign -- the pre-anesthesia evaluation and anesthesia plan. Some coders believe this documentation and notes regarding his medical direction of the CRNA are sufficient. Others have the anesthesiologist sign the CRNA's documents because he is overseeing the CRNA's work and is still responsible for the patient's care. If your local carrier does not specify how to handle the situation, decide what your group's policy will be and ensure everyone follows it.
You’ve reached your limit of free articles. Already a subscriber? Log in.
Not a subscriber? Subscribe today to continue reading this article. Plus, you’ll get:
  • Simple explanations of current healthcare regulations and payer programs
  • Real-world reporting scenarios solved by our expert coders
  • Industry news, such as MAC and RAC activities, the OIG Work Plan, and CERT reports
  • Instant access to every article ever published in Revenue Cycle Insider
  • 6 annual AAPC-approved CEUs
  • The latest updates for CPT®, ICD-10-CM, HCPCS Level II, NCCI edits, modifiers, compliance, technology, practice management, and more

Other Articles in this issue of

Anesthesia Coding Alert

View All