Anesthesia Coding Alert

Question: What do you find to be the best place to pull the diagnosis for anesthesia services? Do you base your coding on the pre-anesthesia note and/or surgeon’s note, or somewhere else?

Nebraska Subscriber

Answer: The pre-anesthesia note can give you a good idea of what to expect for coding, but the operative report will have the most accurate information. That’s because circumstances can change once a case begins, meaning the actual procedure that’s performed might be different from what was planned. The surgical report will have all the details of the case, including some that your anesthesia provider might not have documented. If the coder has access to the operative report, this is the official diagnosis, which should match hospital reported diagnosis code(s). While it is nice for a coder to mirror these diagnosis codes in the anesthesia claim, if you don’t have access to the operative report, report what is documented in the available anesthesia records.

Tip: If your office receives multiple denials for diagnosis coding, consider requesting the operative reports before submitting claims.