anesthesiologist documentation

Hello, all,

Do you routinely code and/or query based on anesthesiologists' documentation?  If so, have you provided any education to the service line?  Which are the most common diagnoses you pick up from anesthesiologists' documentation?

Thank you,



  • Short Answer is ‘yes’..and there  is an official statement from Coding Clinic stating this is logical and permitted.   I have provided ‘some’ education to this service line.   Personally, I find the Anesthesiologists do an excellent job documenting known chronic conditions that impact ASA ratings, such as ICM, HF, Fib, COPD,  Htn, DM, states of CKD.

    P. Evans, RHIA, CCDS
  • Paul can you share the specific coding clinic that references this?

    thank you,


  • Can’t copy right now:  See 3rd Quarter, 2008, page 3.
    Also,  1st quarter 2004, pages 18-19.

    Essence:  “code assignment may be based on other physician documentation as long as there is no conflicting documentation’
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