anesthesiologist documentation

cffernandez44@gmail.comcffernandez44@gmail.com
in Clinical & Coding

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,

Coral

Comments

  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    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
  • aliciasmail@twc.comaliciasmail@twc.com

    Paul can you share the specific coding clinic that references this?

    thank you,

    Alicia

  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    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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