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Anesthesia Pre-op prep time documentation requirements

Sandra m Posted Mon 23rd of February, 2015 13:01:07 PM

What are the minimum documentation requirements in order to be compliant with reporting the patient anesthesia prep time? Considering CMS's definition of anesthesia start time as preparing the patient for the anesthesia services, if the anesthesia provider is only performing a review of the pt.'s chart, can that be considered compliant for documentation purposes, or should there be other functions or elements to consider besides a review of the pt.'s chart? CMS's chapter 12 of the processing manual does not clearly explain this situation. How would this scenario be billed/ considered? Is there any other source documents from other sources that clearly identify this topic?

SuperCoder Answered Wed 25th of February, 2015 02:56:01 AM

Hello,

Anesthesia Start Time:

As per guidelines anesthesia start time begins when the anesthesiologist begins to prepare the patient for the induction of anesthesia in the operating room (or in an equivalent area).

Anesthesia End Time:

As per guidelines anesthesia end is when the anesthesiologist is no longer in personal attendance, that is, when the patient may be safely placed under postoperative supervision.

It means only performing review of the chart is not sufficient to code the service. The anesthesia care during the procedure includes, the administration of fluids and/or blood and the usual monitoring services (e.g., ECG, temperature, blood pressure, oximetry, capnography, and mass spectrometry). And few forms of monitoring (eg, intra-arterial, central venous, and Swan-Ganz) are not oncluded.

For more clarification please follow the link of an article related to anesthesia time and importance of presence of anesthesiologist-
https://www.supercoder.com/coding-newsletters/my-anesthesia-coding-alert/you-be-the-coder-can-you-go-beyond-or-for-start-time-article

Thanks

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