Anesthesia Coding Alert

Question: What documentation do we need from our anesthesiologist to support coding for CVP or PAC catheters? He wrote, "Seldinger technique left IJ 1st attempt" and then "PAC" on his chart. Is that solid enough documentation to stand up to an audit?

Arkansas Subscriber

Answer: You must be able to determine several factors from the documentation before coding the case.

• What is the patient's condition? If the patient has an underlying cardiovascular disease or there is an antici­pation of fluid or blood loss during the surgery, they may require an increased level of monitoring.
• Who provided the service? If the procedure was personally performed by an anesthesiologist, the answer is clear. However, if an SRNA, CRNA, anesthesia assistant, or resident is involved in the case, a handwritten note alone is not sufficient for an auditor to determine who performed the service.
• What service was provided and when? When the provider places a pulmonary artery catheter (PAC), the central venous placement (CVP, code 36555 [Insertion of non-tunneled centrally inserted central venous catheter; younger than 5 years of age] or 36556 [... age 5 years or older], depending on the patient's age) is included and not billed separately unless there is an indication of the need for a separate and distinct CVP. Documentation should include whether two separate access sites are required or if the PAC was performed at a different time based on the patient's changing medical condition.

Although the anesthesia record typically doesn't allow a lot of room for details, an auditor may not "presume" details and the CVP and PAC documentation described above is lacking. Many anesthesia practices have begun using templates to better document the ancillary services they provide, which may be included as a part of the patient's medical record.