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Confused dealing with never ending anesthesia codes? There's more! Every aspect counts when your anesthesia providers keep invasive lines that are distinctly reportable from the average anesthesia service. Keep in mind that line placement is certainly a surgical procedure, therefore the service should be documented prior to a payer will reimburse. Sidestep denials by knowing what anesthesia codes would work and training your anesthesia providers to steadily document these five components of line insertion. 1. Backing Medical Necessity As standard anesthesia care involves so many services, documenting medical requirement for additional lines is key. For instance, the patient might be suffering from coarctation (Anesthesia Codes selection: 747.10, Coarctation of aorta [preductal] [postductal]), which is a narrowing of the aorta in the middle of the upper and lower body branches. That sort of complaint or more general issues such as circulatory problems may also need an added arterial line for the anesthesiologist's monitoring purposes. 2. Keep an Eye on the Clock Your providers must by now be habituated to documenting their start and stop times for any anesthesia case. If they place lines in a case that they expect to bill distinctly, remind them to document each line's start and stop time separately. 3. Pinpoint the Location The operative note must document where the provider placed the line, for instance “right radial artery" or else “right intrajugular." The note doesn't make a change in your anesthesia codes selection; however is decent documentation of the line placement. 4. Verify Barrier Method/Technique In case your physicians give data for PQRS, they must be looking out for ways their documentation can help reporting the anesthesia measures. Documenting sterilized technique or maximal barrier sterile technique (MSBT) supports reporting PQRS (Physician Quality Reporting System) measure 76 (Prevention of catheter-related bloodstream infections [CRBSI): Central venous catheter [CVC] insertion protocol). Measure 76 keeps a record of the number of patients who experience CVC insertion while the provider uses all elements of maximal sterile barrier technique. 5. Name the Provider Even though you have every other detail noted, you'll only be compensated when the chart has provider's name and signature. Medicare guidelines permit a handwritten or electronic signature on orders or other medical record documentation for review. Stamped signatures are not adequate; however the provider could sign her initials on her printed or typed name. Tip: Have a signature log as well as signature attestation statement. This is particularly significant for Medicare patients. In a Medicare audit, they will wish to see these to make certain that the signature is that of the service provider. Final note: Documentation is very important for compliance and reimbursement as it permits capture of the services provided. All charges must be validated by documentation. Keep in mind, in case a service isn't documented, from a reimbursement standpoint it's the same as being undone. The above expert article is brought to you by SuperCoder.com. Click here to know everything about Anesthesia Codes and read the whole article for more accurate and profitable expert coding advice: http://www.supercoder.com/articles/articles-alerts/aca/line-placement-5-keys-unlock-your-invasive-lines-documentation-challenges/
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