Anesthesia Coding Alert

Answer: Anesthesia time starts when you assume control of the patient’s care for the procedure being performed. Typically, anesthesia time starts at the time the patient enters the operating room and you are in constant physical attendance with the patient. If you are delayed and enter the OR later than the patient, your start time begins when you enter the OR. 

 

Anesthesia time stops when you are no longer caring for the patient and have transferred that care to another person (i.e., the PACU staff). This time is typically when you leave the patient’s bedside in PACU. Typically, anesthesia stop time is within 10-15 minutes of the surgical stop time. If this time is longer, there should be a reason cited in the record such as “extra time spent with patient managing laryngospasm.” 

 

Remember: Pre-op and post-op visits are standard parts of anesthesia service and are included in the base units for each anesthesia code. Therefore, don’t bill for time spent talking to the patient in the pre-op area. 

 

Exception: If your patient has a severe anxiety disorder, requires a much larger than average pre-operative sedative, and is personally escorted to the OR by you so you can monitor their status during the transport, then you could start your anesthesia time at the time you administered the sedative. Again, this should be well documented in your record and is a very rare occurrence.