Wiki Guidelines for documentation for Art & CV lines

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Krecher

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Need help obtaining guidelines for documentation for placing arterial line and CV line. We have just started EMR for our anes dept, some physicians are just puting the time and typing art line placed, while others are actually going to the procedure note and documenting. Is there guidelines out there for this? :eek:
 
They have to do a procedure note. The carrier has to see where the line was placed to be able confirm that the code you are reporting is accurate.
 
Thank you, where can I find the guidelines for this? I need something in writing saying that they must have more than just a time and they placed an art line/cv line.
 
You can find this in the Anesthesia Answer Book if you have access to it. It says a procedure note isn't necessary as long as the time and location of the lines are documented on the ane record. We always followed this guideline and had minimal problem getting paid. :)
 
Central lines

The CPT guidelines tell us that in order to qualify as a central venous access catheter or device, “the tip of the catheter/device must terminate in the subclavian, brachiocephalic (innominate), or iliac veins, the superior or inferior vena cava, or the right atrium.” The catheter can be inserted centrally (in the jugular, subclavian, femoral vein or inferior vena cava catheter site) or peripherally (via the basilic or cephalic vein).

http://www.todayshospitalist.com/index.php?b=articles_read&cnt=375

With the EMR they can store a template note and adjust it per case. This note could be added easily. With Catheter infection being one of the new quality measures for hospital reporting. I am sure the hospital they are performing this at would want more than the bare minimum.
 
dwaldman said:
They have to do a procedure note. The carrier has to see where the line was placed to be able confirm that the code you are reporting is accurate.
Click to expand...

I agree with you that EMR templates are available and easily copied from note to note. I agree that a procedure note is the best way to document and that hospitals would probably want them used if available. However, a procedure note is not mandatory. I would also caution against the habit of using copy and paste for EMR. Each procedure and patient is unique. Copying one note into another can be inaccurate and even dangerous. Templates are fine and can save time as long as the practitioners are thorough. Templates and checklists can lead to up-coding and nobody wants to be audited.
 
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