Anesthesia Coding Alert

Question: A physician does not agree with my interpretation of start time. I believe start time is the time the patient goes to the OR and the anesthesiologist takes the vitals and starts preparing them. He believes that if the patient contact starts outside the OR in the holding area and he does his exam, places an IV, and accompanies the patient to OR, that he can have the start time begin in the holding area where he first began contact with the patient. Whats the right answer?

Maine Subscriber

Answer: Your anesthesiologist is correct. The anesthesia start time begins when the provider starts prepping the patient for anesthesia. This does not have to be done in the OR; it can be done in the holding room or another location.

Most carriers start time definition is when the anesthesiologist is in constant attendance. This usually starts outside the OR.

Example: Imagine looking at an anesthesia record for a repair of an umbilical hernia, left inguinal hernia,and excision of right calf mass. The graph across the top of the anesthesia record begins at 7:45 and is timed each 15 minutes (8:00, :15, :30, :45; 9:00, :15, etc). There is activity on the graph beginning in the first block (7:45) and that matches anesthesia start time (7:45).

The operation prep time is 7:54, incision time of 8:12, and end time of 10:00 a.m.

The last activity on the graph is noted at approximately 10:00 a.m., also. Anesthesia end time (transfer to PACU) is 10:10.

The documentation supports the anesthesiologist start and stop time, which should not include any preanesthesia assessment. Note time is before, during,and after surgery and should correlate with the documentation.