Deciphering the Anesthesia Record

By: Judy A. Wilson, CPC, CPCO, CPPM, CPB, COC, CPC-P, CANPC ,CPC-I

DisclosureThis presentation is intended to provide basic educational information regarding coding/billing for anesthesia and not intended to convey coding advice and does not represent the following:

Official policy of the ASA (American Society of Anesthesiologists)

Official policy of the Virginia CMS

Every effort has been made to ensure the information in this presentation is accurate.

Documentation Is Key To Good Care

Three must haves on all Anesthesia Records

1. Pre-Operative Documentation

2. Intra- Operative Documentation

3. Post-Operative Documentation

Pre- Operative Documentation Procedure Summary

Date/Time: 11/02/15 0730

Procedure: EP DEV IMP IV ICD CIU CARDIAC

Location: Hospital EP LAB

Plan: MAC

ASA Physical Status Classification: PS-4 Severe systemic disease that is constant threat to life

Airway

Modified Mallampati Score: II

Airway Evaluation: Potential difficult A/W by exam/Hx

Dentition: Abnormal and Risk of dental injury discussed

Beta Blocker: Patient on beta-blocker prior to admission. Patient given beta-blocker during perioperative period.

NPO Status: Confirmed NPO

Review of Systems: Review of systems per medical, surgical and social history, Sleep Apnea: No

Good functional capacity MET level 4 or more: No

Pre-Operative Documentation

Continued:

Personal and Family Anesthesia History: no anesthetic complications

NPPhysical Exam: Heart: Regular rate/rhythm Lungs: Clear to auscultation

EKG: EKG abnormal, per chart

CXR: CXR abnormal, per chart

Pregnancy: Denies, No LMP recorded. Patient is postmenopausal.

Allergies: Penicillin – Reactions: hivesPast Medical History: Shortness of breath, Heart murmur, Congestive heart failure,

Unspecified, community acquired pneumonia, unspecified deficiency anemia,

Fast heart beat, Vision decreased (glasses), Post-menopausal

History: Substance Use Topics: Smoking Status, Never Smoker; Smokeless tobacco,

Never used; Alcohol Use: No

History reviewed. No pertinent past surgical history.

Pre-Operative Documentation

Continued:

I have informed patient of his/her guardian of the nature and purpose of

the type of anesthesia, the reasonable alternative anesthetic methods,

pertinent foreseeable risks involved and the possibility of complication. I

have explained that an alternative form of anesthesia may be required by

unexpected conditions arising before or during the procedure. Patient or

his/her guardian understand that general anesthesia may be required for

his/her safety or comfort. Questions have been answered to the satisfaction

of patient or his/her guardian who accepts the risk and agrees to proceed

as planned. The above anesthetic review of patient’s medical history,

exam, tests, assessment subsequent anesthetic pain and consent have

been accomplished pre-procedure.

Physician signature.

ASA Status Must be Documented on all

Anesthesia Charts

Physical Status 1 – A normal healthy patient

Physical Status 2 – A patient with mild systemic disease

Physical Status 3 – A patient with severe systemic disease

Physical Status 4 – A patient with severe systemic disease that is a constant threat to life

Physical Status 5 – A moribund patient who is not expected to service without the operation

Physical Status 6 - A declared brain-dead patient whose organs are being removed for donor purposes

These definition can be found in every edition of the ASA Relative Value Guide

Documentation Intra- Operative

Monitored Anesthesia Care

Sedation

Moderate, Conscious, Deep

Regional Anesthesia

Spinal, Epidural, Nerve/Plexus Block

General Anesthesia

ETT (Endotracheal intubation), LMA (Laryngeal mask airway), Mask (Use of a Mask

to introduce the anesthetic), TIVA (Total Intravenous anesthesia)

Documentation of Position Can

Increase Payments

Positions

PRONE

SUPINE

LITHOTOMY

FIELD AVOIDANCE

LATERAL DECUBITUS

Field Avoidance

Any procedure around the head, neck or

shoulder girdle, requiring field avoidance, or any

procedure requiring a position other than supine

or lithotomy, has a minimum Basic Value of 5

regardless of any lesser basic value assigned to

such procedure in the body of the Relative

Value Guide

Documentation of Lines and TEES

Arterial Line (Art. Line

Central Line (CVP Line)

Pulmonary artery catheter (Swan

Ganz/PAC)

Transesophageal echocardiogram (TEE)

Procedure done by Anesthesiologists

ANESTHESIA RECORDSProcedure Summary____________________

Date: 11/02/15

Responsible Provider: Dr. AAPC

Location: Hospital EP LAB

Procedure [code]_____________________

HEART CARTHETERIZATION BIV ICD

Diagnosis [codes] CAD_________________

Staff Role Begin End__

Name: Dr. AAPC ANEST 0728 0911

Antibiotic Verified------------------------------------

11/2/2015

Antibiotic Yes

Given w/in 60 min of incision

Events____________________________________

Date: Time Event Last Edited

11/2/15 0728 Ready for 11/2/15 Dr. AAPC

Procedure 0728_____________

0728 Anesthesia__11/2/15 Dr. AAPC

______________Start________0728 Dr. AAPC

0728 Start Data 11/2/15 Dr. AAPC

Collection 0728 Dr. AAPC

0733 Induction 0807 Dr. AAPC

Patient was identified and procedure verified. The most recent ASA Guidelines were utilized for pre-anesthesia machine/equipment checkout. SpO2 and other appropriate alarms are active. Patient was re-evaluated immediately before starting the induction/procedural sedation and determined to be clinically ready for planned anesthetic and surgery.

Documentation for Lines

Procedure Epidural Placement at the request of the Surgeon for Post-Op Pain

CT Anesthesia Epidural Placement Note

IV access present, noninvasive monitors applied. Patient place in sitting

position. Thoracolumbar sterile pre and drape. 1% lidocaine infiltration #17 G

Tuohy place in T6-T7 epidural space via loss of resistance technique employing

Air after 1 attempt(s).

Epidural catheter: 3cm of catheter in epidural space

Test Dose: Lidocaine 1.5% with 1.200k Epinephrine 3 mL.

Medication: APF Morphine 5mg

Infusion medication: Fentanyl 2 microgram/ml, Bupivacaine 0.125% in 100ml

NSS Comment. Vital signs stable after procedure finished.

Dr. Goofy

Documentation of Epidural Follow Up

Author: Dr. Good Service: Anesthesiology Author Type: Physician

Filed: 11/09/2015 Note Time: 11/09/2015 0709 Status: Signed

Editor Mickey Good, MD (physician)

Epidural Follow Up Note

Pain Level: Pt denies

Nausea: No

Pruritus: No

Condition of insertion site: OK

Medication: Fentanyl 2 microgram/ml, Bupivacaine 0.125% in 100ml NSS

First Chest tube removed yesterday. Final chest tube to be removed today.

Plan: discontinue epidural: catheter removed with tip intact

Documentation of Arterial Line

(ART LINE)

Arterial Line

Start time: 10/1/2015 7:51 AM

End time: 10/1/2015 7:54 AM

Reason:

at surgeon's request and intra operative anesthesia

Procedure Note: Arterial line insertion

Indication: continuous hemodynamic monitoring

Informed consent obtained.

Sterile prep & drape. 1% lidocaine infiltration. 18 Gauge catheter placed in

left radial artery via sterile technique

Documentation of Central Lines

Central Line

Start time: 10/1/2015 8:11 AMEnd time: 10/1/2015 8:21 AM

Reason:

at surgeon's request and intra operative anesthesia

Patient identified. Consent obtained. Patient transferred to cardiac OR 2. Standard ASA monitors applied. Pre-oxygenation. Arterial line placed per anesthesia record. Induction per anesthesia record. Endotracheal intubation per anesthesia record. Patient placed in Trendelenburg position for central venous catheter (CVC) placements and pulmonary artery catheter placement. Universal Protocol completed/time-out conducted prior to central line insertionPrep and technique per CDC protocol. Dynamic ultrasound guidance was not employed. The image(s), if applicable, were placed in the chart.

CVC #1: 4 lumen 8.5 French catheter: Placed in Right internal jugular vein. All ports aspirated and flushed. Sutured. Dressed after surgery completed. Indications: Need/potential for vasoactive infusions; need for multiport access; need for secure, reliable intravenous access; and surgeon requests for postoperative use.

CVC #2: 9 French introducer. Placed in Right internal jugular vein using a separate site. Catheter aspirated and flushed. Sutured. Dressed after surgery completed. Pulmonary artery catheter: Flushed. Balloon checked. Distal port flushed when placed in introducer. Floated easily after chest open. Indications: Cardiac Output/Index; hemodynamic parameters (stroke volume, systemic vascular resistance, etc.); measurement of pulmonary artery pressures; and surgeon requests for postoperative use.

Medicare PQRICap_____gv______ YES Mask______gv____ YES Sterile gown__gv__ YES Sterile gloves___gv_ YES Hand hygeine___gv_ YES Antiseptic prep __gv_YES Large sterile drape_gv_YES

Documentation for Transesophageal

Echocardiography (TEE) TEE at Request of the Surgeon

TEE probe passed, single atraumatic attempt

Patient identified. Consent obtained. Patient transferred to cardiac OR 3. Standard ASA

monitors applied. Pre-oxygenation. Arterial line placed per anesthesia record. Induction per

anesthesia record. Endotracheal intubation per anesthesia record.

Patient placed in Trendelenburg position for central venous catheter (CVC) placements and

pulmonary artery catheter placement. Unable to pass wire into right internal jugular vein; no PA

catheter placed. Possible carotid puncture with seeker needle without hematoma formation

Universal Protocol completed/time-out conducted prior to central line insertion

Prep and technique per CDC protocol.

Dynamic ultrasound guidance was not employed. The image(s), if applicable, were placed in

the chart.

CVC #1: 4 lumen 8.5 French catheter: Placed in Right external jugular vein. All ports aspirated

and flushed. Sutured. Dressed after surgery completed.

Indications: Need/potential for vasoactive infusions; need for multiport access; need for secure,

reliable intravenous access; and surgeon requests for postoperative use.

Anesthesia Record Continued:

Assessments--------------------------------------------------

11/2/2015 11/2/2015 11/2/2015 11/2/15

0730 0745 0800 0815

EKG NSR;Bundle NSR;Bundle NSR;Bundle NSR;Bundle

branch branch branch branch

______block block block block______

O2 room air simple face simple face simple face

Device mask mask mask_____

11/2/2015 11/2/2015 11/2/2015

0830 0845 0900

EKG NRS; Bundle NSR; Bundle NSR; Bundle

blanch block blanch block blanch block____

O2 Simple face Simple face Simple face

Device mask mask mask___________

0753 Antibiotic11/2/2015 DR. AAPC

Verified 0756 DR. AAPC

0755 Procedure 11/2/2015 DR. AAPC

Start 0807 DR. AAPC

0756 Position 11/2/2015 DR. AAPC

0756 DR. AAPC

0813 Quick Note 11/2/2015 DR. AAPC

0817

Dr. Mickey informs that air may have been entrained. Mild hypoxemia expected_______

0853 Emergence 11/2/2015 DR. AAPC

0859____________________

0910 Stop Data 11/2/2015 DR. AAPC

Collection 0910____________________

0911 Anesthesia 11/2/2015 DR. AAPC

Stop 0911______________________

Anesthesia Record Continued:

Lines, Drains, and Airways____________________

Type Details Placement Removal

PIV Location Left, 02/7/15 1450 11/3/15 1107

Antecubital; Size by RN By RN

20 gauge; Pre-

__ existing No_______________________________

PIV Location Rt 11/2/15 0630 11/315 1107

Antecubital; Size RN RN

20 gauge; Pre-

existing No

Positioning_________________________

11/2/2015

0758

Position Supine__________________

Arm Bilat arms tucked

Position____________________________

Checklist___________________________

11/2/2015

0000

Anesthesia Check list _________________________________

Anesthesia machine/airway per latest ASA guidelines, as indicated; Audible, Alarms On; Pulse oximeter, EKG, Gas, Analyzer ETCO2;O2 analyzer, Gas humidifier; Infusion pump; Anesthesia apparatus checked._______________________

NIPP Site Arm L

Temp Src Available

Anesthesia Record Continued:

Case Tracking Events_______________________________________________________

Event Time In

Anesthesia Interview Complete Mon Nov.2, 2015 0728______

Setup Complete-Room Ready

In Room

Procedure Start

Procedure End

Out of Room

PACU in

Post Anesthesia Note

Patient is recovering from his/her anesthesia

His/her most recent vital signs are: Temp: 37 C (98.6 F), Pulse 82, Resp: 21, BP;

152/89 mmHg, BP Mean: 110 MM HG SpO2: 100%

His/her airway is patent. He/she is awake and can follow commands after her

anesthetic. Her pain is adequately controlled. Her vital signs indicate

adequate postoperative hydration. PONV is not clinically significant.

Healthcon, MD

Reading the Anesthesia Records

V = systolic

^ = diastolic

X = MAP (Mean Arterial Pressure)

O = respiratory rate

O filled in all dark = heart rate

Generally if more than 70 mg of propofol given at one time it

becomes a GA or General

Almost all inductions for GA (General) use IV propofol or

etomidate

AnesthesiologistA.K.A. THE PAIN FIGHTER

EASING YOUR PAIN THAT’S WHAT THEY DO.

DEDICATED TO TAKE YOU ON A WONDEROUS RIDE AND BRING

YOU BACK HOME AGAIN.

CASE # 1

Procedure Summary

Procedure Thoracic Ascending Aorta Graft and ARR With Bypass

ASA PS-4 Severe systemic disease that is a constant threat to life

Pre op diagnosis: Aneurysm

Post op diagnosis: Aneurysm

Name Role Begin End

Dr. Judy Anesth 0731 1544

Assessments

Sinus bradycardia

Device: Simple face mask

Device: Ventilator

Events Last

Date Time Event Edited

11/5/15 0712 Ready for procedure 0731

0732 Anesthesia start 0732

0732 Start Data Collection 0732

0744 Induction 0744

0746 Intubation 09100800 Quick Note 0919 Procedure Note: Central Line Insertion

Indication: Need/potential need for vasoactive infusions. Need for secure, reliable IV access and at the Surgeons, Dr. Dman requested placement for postoperative use. Universal Protocol prior to Central Line Insertion and PAC Placement. Informed consent obtained. Sterile pre-op & drape. Rt. Internal jugular vein Quadruple lumen catheter place via sterile Seldlngar technique employing cook needle without incidental carotid puncture.

Medicare PQRS

Cap-----------YES

Mask----------YES

Sterile grown—YES

Sterile gloves—YES

Hand hygiene—YES

Antiseptic prep—YES

Large sterile Drape: YES

Case # 1 Continued:

Procedure Note: Swan-Ganz Catheter Insertion

Indication: Cardiac Output/Index. Hemodynamic

parameters. Measurement of pulmonary arterial

pressures and Surgeon requests placement for

postoperative use. Informed consent obtained.

Sterile prep & drape. Rt internal jugular vien 9.0

French introducer sheath place via sterile

seldlnger technique employing cook needle w/o

incidental carotid puncture. Sean-Ganz (PAC)

catheter floated to position in pulmonary artery.

CASE # 1 CONTINUED

EVENTS CONTINUED

0845 Quick Notes 0920

Well lubricated TEE was placed on first

attempt with gentle pressure w/o

difficulty.

0852 Antibiotic Verified

0852 Procedure Start

1000 CV Bypass Initiated

1011 Quick Note: Ice bags place around head Protective goggles place over eyes

1018 Quick Note:

1025 Aortic Clamp On

EVENTS CONTINUED

1027 Quick Note:

1040 Aortic Clamp Off

1153 Defibrillation

1208 Active Warming

1247 CV Bypass Ended

1410 Quick Note: Factor VII ½ dose

1518 Quick Note: requested the second half of a Factor VII dose

1522 Quick Note: TEE was removed w/o difficulty. An OG tube was placed easily. Clear gastric aspirate was obtained.

1529 Stop Data Collection

1529 Anesthesia Stop

Anesthesia RecordsCASE # 1

1. What is the anesthesia start time?

2. What type of anesthesia was use?

3. What lines were placed and why?

4. Was a TEE done?

5. Was the patient on bypass?

6. What time did the patient go on bypass?

7. What time was the patient taken off of bypass?

8. What time did anesthesia stop?

9. Was there info in the chart to bill out your PQRS?

10.What PS status was this patient?

CASE (1) ANSWERS

ANSWERS

1. START TIME 07:30

2. General Simple Face Mask

3. Central Line, Swan Ganz

4. Yes

5. YES

ANESWERS

6. 10:00

7. 12:47

8. 15:44

9. YES FOR CVP

10. PS - 4

CASE TWO CONTINUED:Procedure Notes

Last edited 11/02/15 0800 Dr. Tracy

TEE

Tee probe passed, single atraumatic attempt

Patient identified. Consent obtained. Pt. transferred to cardiac OR3. Standard ASA monitors applied. Pre-oxygenation. Arterial line place per anesthesia record. Induction per anesthesia record. Endotracheal intubation per anesthesia record. Pt. place in trendelenburg position for central venous catheter (CVC) placement.

Universal Protocol completed/time-out conducted prior to central line insertion

Prep and technique per CBC protocol.

Dynamic ultrasound guidance was not employed. The image(s), if applicable, were placed in the chart.

CVC #1: 4 lumen 8.5 French catheter: Place in left internal jugular vein. All ports aspirated and flushed. Sutured. Dressed after surgery completed.

Indications: Need/potential for vasoactive infusions; need for multiport access; need for secure, reliable intravenous access, and surgeon requests for post operative use.

Medicare PQRS; CAP YES, MASK YES, STERILE GOWN YES, STERILE GLOVES YES; HAND HYGEINE YES; ANTISEPTIC PRE YES, LARGE STERILE DRAPE YES.

Anesthesia Record

Case # 2

1. What is the anesthesia start time?

2. What type of anesthesia was use?

3. What lines were placed and why?

4. Was a TEE done?

5. Was the patient on bypass?

6. What time did anesthesia stop?

7. Was there info in the chart to bill out your PQRS?

8. What PS status was this patient?

CASE # 3

Procedure Summary

Procedure: Pericardial Window (33025)

Transesophageal Echocardiography (93312)

ASA PS-4 Severe systemic disease that is a constant threat to life emergent

Pre-op diagnosis: Pericardial effusion

Post-op diagnosis: Pericardial effusion

Name Role begin end

Dr. Eric ANESTH 1510 1639

ASSESSMENTS

Sinus tachycardia

Partial rebreather mask Ventilator

Anesthesia: General

EventsDate Time Event Last Edited

10/30/15 1510 Anesthesia start 1510

1512 Start Data Collection

Patient was identified and procedure verified. The most recent ASA Guidelines were ultilizedfor pre-anesthesia machine/equipment checkout. SpO2 and other appropriate alarms are active. Pt. was re-evaluated immediately before starting the induction/procedural sedation & determined to be clinically ready for planned anesthetic and surgery.

1525 Intubations

1548 Antibiotic Verified

1548 Active Warming Device Used

1552 Procedure Start

CASE 3# CONTINUED:1623 Stop Data Collection

1636 Report Given

1639 Anesthesia Stop

TEE

Reason: At surgeon’s request and intra operative anesthesia. Well lubricated probe place atraumatically without resistance on first attempt. Finalized, electronically signed & saved.

Central Line

Reason: At surgeon’s request and intra operative anesthesia. Patient identified. Consent obtained. Patient transferred to cardiac OR 2. Standard ASA monitors applied. Pre-oxygenation. Induction per anesthesia record. Endotracheal intubation per anesthesia record. Patient place in Trendelenburg position for central venous catheter (CVC) placements and pulmonary artery catheter placement. Universal protocol completed/time-out conducted prior to central line insertion Pre and technique per CDC protocol. Dynamic ultrasound guidance was not employed. The image(s), if applicable, were place in the chart.

CVC #1 4 lumen 8.5 French catheter: Place in Rt. Internal jugular vein. All ports aspirated and flushed. Sutured. Dressed after surgery completed.

Indications: Need/potential for vasoactive infusions; need for multiport access; need for secure, reliable intravenous access, and surgeon requests for postopertative use

CASE # 3 CONTINUED:

MEDICARE PQRS

CAP YES

MASK YES

STERILE GOWN YES

STERILE GLVOES YES

HAND HYGEINE YES

ANTISEPTIC PREP YES

LARGE STERILE DRAPE YES

Anesthesia Record

Case # 3

1. What is the anesthesia start time?

2. What type of anesthesia was use?

3. What lines were placed and why?

4. Was a TEE done?

5. Was the patient on bypass?

6. What time did the patient go on bypass?

7. What time was the patient taken off of bypass?

8. What time did anesthesia stop?

9. Was there info in the chart to bill out your PQRS?

10.What PS status was this patient?

Thank You for Attending …

JUDY@ANES.HRCOXMAIL.COM