Anesthesia Coding Alert

Question: A patient was admitted through the Emergency Department and went immediately to surgery. The case was so critical that there was no time for a pre-anesthesia examination. How do we document and bill for the anesthesia?

Wyoming Subscriber

Answer: The anesthesiologist should bill his services in the same manner as any other anesthesia service. The base value of anesthesia codes includes all usual pre- and postoperative visits. When the anesthesia provider is unable to perform a pre-anesthesia exam, he should include an explanation in place of the pre-op assessment. For example, your provider might note the patient's critical status and any other pertinent information to explain why he wasn't able to perform the usual pre-op service.