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July 28, 2016

Understanding – and Abiding By – Anesthesia Documentation Requirements

July 28, 2016

anesthesia documentation

Compliance, for an anesthesia practice, is quite different from other medical practices and specialties – and can even differ within the anesthesia field.

Because so much depends on proper compliance, practices need to understand what is required of them when it comes to complying with rigorous documentation requirements. However, many providers – even those with decades of experience – have trouble keeping up with the myriad documentation standards out there. This is mostly because documentation guidelines change regularly, so what was in effect five years ago – or even a year ago – may not be in place today.

Here, we’ll provide a general overview of anesthesia documentation requirements. Note that you can get a more thorough understanding of all requirements by contacting a billing and coding specialist that works with anesthesia practices.

Examining the Basic Requirements

National standards for documentation come from the National Committee for Quality Assurance (NCQA), which publishes the Guidelines for Medical Record Documentation. In the guidelines, there are 21 separate elements. Not all of these apply to anesthesia practices.

The ones that do apply specify that each page in a patient’s record must contain the patient’s ID number or name. Additionally, all medical record entries must have the author’s ID, which can come in the form of initials, an electronic ID, or a handwritten signature. Finally, the record must be legible to others who read it, beyond the writer.

There are other guidelines available, such as the ones from the American Association of Nurse Anesthetists (AANA). Perhaps the most commonly used guidelines, other than NCQA, come from the American Society of Anesthesiologists (ASA). They don’t publish documentation guidelines per se, but do have several general guidelines that can be found here.  

Documentation Standards for Anesthesia Care

When we get into more specific guidelines (using those published by ASA), we break down the standards into three areas: pre-anesthesia care, intra-operative care, and post-operative care.

Pre-Anesthesia Care

Before anesthesia is administered, CMS mandates that pre-anesthesia documentation be signed by a medical directing anesthesiologist. Additionally, there are a few things that need to happen with a patient that must be documented, including:

  • Discussing the patient’s medical history, including any prior experiences with anesthesia
  • Examining a patient’s physical health for risk management
  • Ordering any tests and consultations that are necessary prior to care
  • Ordering any medications for pre-operative care
  • Obtaining and documenting consent from the patient before care is administered

As mentioned, providers must be careful to record that all steps were taken prior to the delivery of care.

Intra-Operative Care

During the administration of care, there are two standards. The first standard, as dictated by ASA, is that qualified anesthesia personnel need to be present in the room while all general and regional anesthetic care is delivered (including monitored anesthesia care).

The second standard is that qualified personnel should, during the administration of care, constantly monitor a patient’s circulation, temperature, ventilation, and oxygenation.

As with anything, adherence to these standards should be documented.

Post-Operative Care

Finally, standards for post-operative care stipulate that patients should be admitted to a post-anesthesia care unit (PACU) or another equivalent area, unless ordered to do otherwise by the anesthesia provider. The provider is responsible for the patient until a PACU can take over.

How Auditors Review Documentation

Documentation becomes critically important whenever a practice faces an audit from an auditor.

Auditors check documents to determine, among other things, that the anesthesia provider continuously monitored the patient and that the anesthesia time was properly documented. For example, auditors want to see notation that the provider checked the patient’s vitals once every five minutes at the very least. Additionally, auditors will check your recorded anesthesia time against records from the PACU and operating room. They may not match exactly, but they need to be very similar.

Auditors also review records for use of anesthesia modifiers. Use of modifiers, and medical direction in general, is covered by the Medicare Claims Processing Manual from CMS, which defines medical direction as: performing a pre-care evaluation, prescribing an anesthesia plan, personally participating in the most difficult portions of care, making sure that all procedures not personally administered are done so by a qualified anesthetist, monitoring anesthesia administration at regular intervals, staying present and available, and providing post-anesthesia care.

There are allowed exceptions, which are covered in more detail in the manual.

Ensuring Compliance with Regular Record Review

Staying compliant means constantly reviewing records to ensure they are complete and accurate, as well as conforming to standards. Internal review processes are exceptionally useful, provided that the reviewer and the record creator are two different people.

Compliance is crucial. Regular reviews from internal and external sources are strongly recommended. Every practice needs a formal plan for compliance, with written processes and standards to make sure all claims abide by standards established by CMS and insurers, and to ensure documents are correct.

Consult with a billing specialist to learn more about guidelines and standards for claim documentation and how to fully comply with them.


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