How Complete Is Your Anesthesia Record?

doctor filling out anesthesia record for medical billing in patient chart

Medical billing is all about appropriate documentation. With it, anesthesia cases can be billed efficiently with fewer delays in payment. This article is intended to detail the top documentation fields that every anesthesia record should contain.

Staffing Information and Start/Stop Times

All records should include the name and provider type for each anesthesia practitioner involved in the case, along with their respective times. Intraoperative handoffs (relief) should also be charted. One area that practices often miss is discontinuous pre-op spinals, used as part of the primary anesthetic. This time is billable, but is frequently overlooked by billing companies when placement time is charted solely on the block note and not included on the anesthesia record.

Final Surgical Procedure(s) Performed

Most anesthesia records have a section for “procedure”, but is it populated with the planned procedure or the final procedure(s) performed? Documenting the latter will ensure that you are not underpaid for your clinical services provided.

Final Diagnosis

Like surgical procedures, recording a post-operative diagnosis can be helpful in your collection efforts. For example, a screening colonoscopy that is converted to a polypectomy pays one additional unit for Medicare. This can be detected by having a field to record post-operative diagnoses. Ideally, groups should document “colonoscopy converted to polypectomy” in the procedural section of the anesthesia record, but if they forget, the diagnosis helps to alert coders of the change.

Final Mode of Anesthesia

All records should include a section for final anesthesia type (General, MAC, Regional, etc.). Like procedural and diagnosis documentation, this should not be charted before the case starts, as the designation often changes intraoperatively. Acute pain blocks are non-payable when billed with MAC anesthesia, so make sure to note when the surgeon books a MAC anesthetic that is converted to a General (defined as any loss of consciousness, regardless of airway access).

ASA Physical Status

This data element is collected during pre-op, but not all anesthesia records have a designated place to chart it. Since billing companies don’t always get a copy of the pre-anesthesia assessment, it’s best to include this item on your intraoperative record. Many payers reimburse more for ASA 3 and above.

Qualifying Circumstances – Emergency and Deliberate Hypotension

There are separately billable codes for these items, so they should be documented in a consistent manner within your anesthesia record. “Emergency” is defined as a potential threat to life or limb, at the discretion of the anesthesia provider. Controlled Hypotension should include a checkbox for “surgeon request”.

Acute Pain Blocks

Groups often chart blocks within a separate module of the EMR from the anesthesia record. For this reason, there should be some notation to the block note within the anesthesia record, so that coders know to pull supporting documentation and submit a charge. For groups that document blocks on their anesthesia record, data elements should include the performing provider, placement start/stop times, the block’s primary intent (post-op pain vs. anesthesia), surgeon request, and use of ultrasound.  

Invasive Monitoring Lines

Like Pain Blocks, there should be a section in the record for Invasive Monitoring Lines. This should include the performing provider, placement time, and U/S guidance where applicable. There should also be a checkbox for “two separate sticks”, to represent when a CVP and Swan-Ganz catheter are placed on the same patient.

Medical Direction

For Care Team Practices, each record should include documentation to confirm that the anesthesiologist was present at induction and emergence, provided frequent monitoring, and remained immediate available throughout the case. Although there are 3 other TEFRA requirements for medical direction, they’re not intraoperative events and are documented elsewhere.

Obstetrical Anesthesia – Time in Attendance

Some Medicaid and commercial insurance plans reimburse for time in attendance only, for labor and delivery cases. If you bill to one of these plans, your record should include a section for “face to face time”, for insurance purposes. This requires charting in-room and out-of-room times, to capture when the anesthesia provider is physically present with the patient. Although this can be somewhat of a charting nuisance, it’s better than a repayment obligation down the road.

Hal Nelson, Vice President Anesthesiology Services


Hal Nelson, CANPC
has 30 years experience on both the payer and RCM side, with a focus in Anesthesia. He formerly worked as a senior claims approver at United Healthcare, as well as a compliance officer for multiple national billing companies. He has also taught the CPC coding curriculum collegiately in Atlanta. His broad based experience ensures that MSN clients will have a resource for documentation and billing issues. His past speaking engagements include ASA, MGMA, Dartmouth, and Johns Hopkins. 

This educational guide was prepared as a tool to provide education for documentation and coding. It is not intended to affect clinical treatment patterns. The material provided is for informational purposes only. Efforts have been made to ensure the information within this document was accurate on the date of distribution. Reimbursement policies vary from insurer to insurer and the policies of the same payer may vary within different U.S. regions. All policies should be verified to ensure compliance. CPT® codes, descriptions and other data are copyright of the American Medical Association (or such other date of publication of CPT®).All Rights Reserved. CPT® is a registered trademark of the American Medical Association. Proprietary and confidential document.  All rights reserved. No part of this document may be reproduced or used in any manner without the written permission of MSN Healthcare Solutions, LLC.