07/02/18 – Complete documentation helps ensure the highest possible base payment for your time.

Complete documentation helps ensure the highest possible base payment for your time.

Incomplete documentation can lead to incorrect code selection and consequently a possible

decrease in base unit.  Use this handy chart to check your documentation to make sure you

aren’t leaving out specifics that would allow for an accurate code selection and often a higher

value anesthesia code.  Your time is important – we want to ensure you are getting the best

possible rate for every procedure.

 

 

If the procedure was… Document if this was actually performed…
Diagnostic knee arthroscopy (3 base) Diagnostic knee arthroscopy with treatment (4 base)
Spinal fusion (8/10 base) Spinal fusion that includes 2 or more disc spaces or uses instrumentation (13 base)
Total hip (8 base) Total hip revision (10 base)
Craniotomy, not otherwise specified
(11 base)
Craniotomy, vascular procedures (15 base)
Ankle Arthroscopy (3 base) Achilles Tendon / Gastrocnemius (5 base)
Radical mastectomy (5 base) Radical mastectomy with internal mammary note dissection (13 base)
Intrathoracic procedures on the trachea and bronchi (17 base) Tracheobronchial reconstruction (18 base)
Cystourethroscopy (3 base) Cysto with manipulation or fragmentation etc. Urethral stone (5 base)
Hernia lower abdomen (4 base) Hernia ventral/incisional (6 base)
Extracorporeal shockwave lithotripsy
(ESWL) (5 base)
ESWL with water bath (7 base)

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