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?


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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