Anesthesia Coding Alert

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 Subscriber

Answer: 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.