Importance of Post Evaluation within 48 hours

Importance of Post Evaluation

Importance of Post Evaluation within 48 hours

Importance of Post Evaluation within 48 hours

By Marcy Garuccio, ACS-AN, CANPC, CPMA, CPC, SME, Fellow; Director of Coding and Documentation Education

What happens when the post-anesthesia evaluation is not completed or signed within 48 hours?

Before addressing this question, it is important that we understand it.  Centers for Medicare and Medicaid Services (CMS), the Conditions of Participation (CoP), as well as the American Society of Anesthesiology (ASA), have standards of care; requirements for entities providing services to patients that ensure good patient care.

In anesthesia, one of the requirements is that a post-operative visit is provided and documented by a qualified individual within 48 hours of the anesthesia service provided. The calculation of the 48-hour timeframe begins at the point the patient is moved into the designated recovery area. The standard of care requires the patient’s ability to participate in this evaluation, i.e., answer questions appropriately. If state law permits, it may be completed after discharge of the patient, so long as it is completed within 48 hours.

My recommendation would be to encourage compliance with this requirement and complete the post-anesthesia evaluation within 48 hours. Not only is it good patient care and practice standards, but it keeps the servicing facilities in good compliant standings.

One way to achieve this goal is to have a hard stop within your practice management system, prior to exceeding the 48 hours; for all services provided, for all required elements.  This allows for proper documentation in a timely fashion. Thus, providing good compliance measures to reduce a poor audit finding, and the possibility of exclusion from insurance programs.

Paper charting systems make meeting these requirements a bit tougher, a tracking system should be in place to assure that all necessary requirements are being met.  Standard of care requirements as well as corrective action plans, may be addressed in the hospital or facility policies and procedures manual. Check with your facilities as well as your legal team when uncertain.

Resources to review to confirm this information:

CMS Manual System – Pub 100-07 State Operations (482.52)

ASA – Post-Anesthesia Evaluation

Federal Register 42 CFR Part 482.52 Condition of participation: Anesthesia Services