06/22/17 – 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 reporting is to have accurate and complete documentation.  A complete description of the surgical procedure as well as all procedures performed should be documented.

Below are 5 items that the coder’s at SupportMed find to be missing the most from documentation:

  1. Hardware or multiple levels for spinal procedures – if hardware was used or if the procedure was performed on multiple levels (3 vertebral bodies with 2 interspaces), the base unit can bump up by 5 units, 00630 with 8 units vs. 00670 with 13 units.


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


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


  1. D&C’s with hysteroscopy – if the 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 – if the procedure was done on the upper abdomen, the ASA code is 00790 at 7 base units, if it was done on the lower abdomen, the ASA code is 00840 at 6 base units. Please make sure to document upper vs. lower abdomen.

No comments so far