02/25/2019 – Complete documentation = accurate coding

Question: What are some key items we should be documenting on our records to make sure SupportMed is able to choose the most specific and highest base anesthesia code?

Answer:

The key to correct coding and reporting is to have accurate and complete documentation.  Two guiding principles are key to this documentation: (1) a complete description of the surgical procedure itself, and (2) a complete description of all ancillary services and/or other procedures performed.

Below are the top five omissions or issues, as judged by SupportMed’s professional coding team, that are found to be absent or missing from anesthesia documentation:

  1. Hardware or multiple levels for spinal procedures – When hardware is used or if the procedure was performed on multiple levels (3 vertebral bodies with 2 interspaces), the base service increases by 5 units (e.g., 00630 with 8 units vs. 00670 with 13 units).

 

  1. One lung ventilation – When a procedure is performed with one lung ventilation, the base unit increases by 3 units. One lung ventilation can be documented by simply writing OLV on the record.

 

  1. Testing for cardioverter-defibrillators – When defibrillator functions are tested, the service increases by 3 units. Please make sure to document that testing was done in addition to placing the defibrillator.

 

  1. D&C’s with hysteroscopy – When surgeon performs just a D&C for vaginal bleeding, the code is 00940 at 3 base units. If a hysteroscopy was used in addition, the procedure bumps up to code 00952 with 4 base units.

 

  1. Upper vs. lower abdomen – When procedure is performed on the upper abdomen, the ASA code is 00790 at 7 base units vs. performed on the lower abdomen, the ASA code is 00840 at 6 base units. Always document upper vs. lower abdomen.

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