Anesthesia Coding Alert

Question: This is an elementary question, but I’m new to anesthesia coding. Where is the best source of information for me to pull the diagnosis for anesthesia services?

Nebraska Subscriber

Answer: If you have access to the operative report, that should be your first choice for diagnosis information. It will have more details about procedure and is less likely to be questioned by the insurance company. Basing the diagnosis off the pre-anesthesia note is your only choice in some cases, but not ideal since circumstances – and even procedures – can change from what was anticipated once the operative session begins.