Anesthesia Providers Need to Be More Specific in 2023
By Marcy Garuccio, ACS-AN, CANPC, CPMA, CPC, SME, Fellow; Director of Coding and Documentation Education
With the new swift changes in health care, anesthesia providers need to be more specific in their documentation of services rendered.
In 2021, the OIG recovered a record high of over two times the amount of take backs from the year before.
With increased scrutiny in medical documentation, anesthesiology providers need to be aware of the importance of using post-surgical and post-procedure diagnosis.
Another area often neglected is the physical status assignment. It’s important to remember that only anesthesia providers can make that assessment and assignment.
If it is missing and documentation supports a healthy patient, we, as coders, cannot assume a number. The AMA CPT instructs that this information needs to be coded; the example they provide is 00100-P1.
Many may wonder why this is important, and there are multiple answers:
The first is that the assignment distinguishes the complexity of the anesthesia service provided. A patient with hypertension and/or diabetes may be a PS2 in one session because those illnesses may be mild and well controlled, but on another day, maybe a PS3 because they have become severe.
Some payer policies allow anesthesia for specific procedures when the patient is a PS3 with certain co-morbidities, and would rely on the documentation supported for that session. I also recommend specificity in those co-morbidities and systemic illnesses.
Unspecified conditions often are not permitted in policies requiring medical necessity, for example, “obesity, unspecified E66.9”, may not be on a policy, however, if documentation notes “morbid obesity E66.01”, that may be supported by a policy.
Lastly, many commercial payers will reimburse the P3 to P5 additional units, but the PS must be on the claim form and often must be supported by an ICD-10-CM; check your payer policies and contracts.
Having this valuable information documented from the start will expedite coding, claim to process, and reimbursement while avoiding sending back inquiries and amendments.