Anesthesia Coding Alert

Question: Our anesthesiologist wrote, "Seldinger technique left IJ 1st attempt" and then "PAC" on his chart. Is that enough documentation to stand up to an audit? If not, what documentation do we need from the anesthesiologist to support coding for CVP or PAC catheters?

Answer: You must be able to determine several factors from the documentation before coding the case.

• What is the patient's condition? If the patient has an underlying cardiovascular disease or there is an anticipation of fluid or blood loss during the surgery, they may require an increased level of monitoring.
• Who provided the service? If the procedure was personally performed by an anesthesiologist, the answer is clear. However, if an SRNA, CRNA, Anesthesia Assistant or resident is involved in the case, handwriting alone is not sufficient for an auditor to determine who performed the service.
• What service was provided and when? When a pulmonary artery catheter (PAC) is placed, the central venous placement (CVP - 36555 or 36556, depending on patient's age) is included and not billed separately unless there is an indication of the need for a separate and distinct CVP. Documentation should include whether two separate access sites are required or if the PAC was performed at a different time based on the patient's changing medical condition. This information is found on pages 48 " 50 of the American Society of Anesthesiologists 2010 Relative Value Guide®.

Although the anesthesia record typically doesn't allow a lot of room for details, an auditor may not "presume" details and the CVP and PAC documentation described above is lacking. Many anesthesia practices have begun using templates to better document the ancillary services they provide, which may be included as a part of the patient's medical record.

Although Physician Quality Reporting Initiative (PQRI) is not yet mandatory, it is associated with both these codes for anesthesia practices. The required documentation elements for maximum sterile barrier technique are not met. By 2015, it will become mandatory and practices who do not report will have their Medicare payments reduced by 1.5 percent. Now may be a good time to discuss a template for documentation, which may include PQRI elements.