NAMAS Webinar Q&A: Anesthesia Services 11/12/2019

Post here your questions regarding auditing ,coding, documentation, and compliance. Also, join in on the conversation- help your fellow auditors and compliance professionals in the industry.

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Below are the questions received during our recent webinar, Anesthesia Services, originally presented on November 12, 2019. These questions have been answered by the webinar presenter, Paul Spencer, CPC, COC.

Question 1
In a day of electronic medical records, does all the documentation for dx codes have to be within the anesthesia pre exam or the anesthesia record OR can you obtain the dx from operative report, lab results, radiology reports etc?
Answer 1:
In answer to your question with regard to a narrative diagnosis, and where you would pull that from in the case of billing and coding, ideally, it is best to pull it directly from the anesthesia record. In the absence of that, the postoperative diagnosis indicated on the operative report should be used in selecting an ICD-10 code.
As there may be an operative session that has multiple procedures involved, you will want to make sure that the post-operative diagnosis selected is most appropriate to the anesthesia CPT code that is selected for billing.

Question 2:
If a twin delivery. Baby A delivered Vaginal and Baby B delivered C-Section... How would we code it out? Technically it's not a Labor to C-Section since baby A was delivered Vaginally right? Please advise?
Answer 2:
This is a great example. In the end, the anesthesia code used would indeed be for the c-section, as it is of a higher base unit value than the vaginal delivery. With regard to the time, the calculation of the time on what methods were used. If the mom was in the OR for both deliveries, the total anesthesia time is easy to calculate. If the patient had an epidural prior to the c-section, there will need to be time added to the total OR time to take into account the placement and management of the epidural prior to the c-section.
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