The Importance of Documenting Surgical Procedures at the End of Each Anesthesia Case

documenting surgical anesthesia cases

I am frequently asked the question, “What is the top cause of lost revenue for anesthesia practices?” My answer is always the same – anesthesia providers who pre-populate the procedural section of their anesthesia record (based on the scheduled surgery), and never review this field at the end of the case for possible revision.

This documentation phenomenon has existed for decades. For whatever reason, anesthesia providers have historically been reluctant to ask surgical staff exactly what was done at the conclusion of each case, thus causing the planned surgery to become the “de facto” procedure of record.

Although AIMS and EMRs now help in capturing this information, the procedural data still has to be input by someone, and this information may or may not represent the post- operative detail required to optimize anesthesia collections.

What Makes Anesthesia Billing Unique?

From a billing perspective, anesthesia is unique in that its payment is tied to both “base” and “time” units. Base units represent the value of the surgical procedure(s) performed, while
time units reflect each 15 minutes of anesthesia clinical activity. 

When more than one surgical procedure is performed during the same operative session, coders must review the base unit value for each procedure and assign a single anesthesia code that represents the highest value (with total time). 

As you might imagine, anesthesia practices who chart only the scheduled surgical procedure are often underpaid for the clinical work that they perform, or have unnecessary delays in billing when coders ask for greater specificity (examples below):

  • Diagnostic Thoracoscopy w/o one-lung vent (8 base units)
  • Diagnostic Thoracoscopy w/ one-lung vent (11 base units)
  •  Surgical Thoracoscopy/Thoracotomy w/o one-lung vent (12 base units)
  • Surgical Thoracoscopy/Thoracotomy w/ one-lung vent (15 base units)

  • AICD w/o active testing (4 base units)
  • AICD w/ active testing (7 base units)

  • CABG w/ pump oxygenator (18 base units) 
  • CABG w/o pump oxygenator (25 base units)

  • Lumbar Spinal Fusion w/o Instrumentation (8 base units)
  • Lumbar Spinal Fusion w/ Instrumentation (13 base units)
  • Cervical/Thoracic Spinal Fusion w/o Instrumentation (10 base units)
  • Cervical/Thoracic Spinal Fusion w/ Instrumentation (13 base units)

  • Screening Colonoscopy (3 base units – Medicare)
  • Screening Colonoscopy w/ Polypectomy (4 base units – Medicare)
  • Combined Upper/Lower GI (5 base units)

  • Diagnostic Knee Arthroscopy (3 base units)
  • Surgical Knee Arthroscopy (4 base units)
  • Diagnostic Shoulder Arthroscopy (4 base units)
  • Surgical Shoulder Arthroscopy (5 base units)

  • C-Section (7 base units)
  • Laboring C-Section (8 base units)

  • Anesthesia for Chronic Pain Block – Other than Prone position (3 base units)
  • Anesthesia for Chronic Pain Block – Prone position (5 base units)

  • TURBT – Lesion size < 0.5cm (3 base units)
  • TURBT – Lesion size ≥ 0.5cm (5 base units)


For anesthetizing locations still using paper records, it is paramount that providers supply detailed and accurate surgical descriptors on each of their anesthesia records. This can only
be accomplished by reviewing such information at the conclusion of each case, to ensure that nothing has changed from the planned procedure. 

For those using electronic anesthesia records where the surgical field is pre-populated, pay close attention to the data output (should be post-procedure and not pre-procedure). Doing so will help to improve the efficiency of your billing operations and ensure that your practice is paid for the valuable clinical services that you perform.

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. 

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