Anesthesia Documentation Items to Ensure Maximum Collections

nurse entering anesthesia documentation items to ensure maximum collections

Top 10 Anesthesia Documentation Items to


Billing for the specialty of anesthesia is somewhat of an art form. The key is for coders to know what to look for within the charting process, and to proactively communicate documentation trends to their respective practices. Listed below are ten common issues that, if not detected, can lead to significant lost revenue for practices.


Accurate description of Surgical Procedure(s) performed

Although Anesthesia is billed with unique time-based codes, such codes can quickly change when the surgeon modifies the planned procedure. Take, for example, a diagnostic knee arthroscopy that’s converted to a medial meniscectomy. The anesthesia code for the latter procedure pays one additional unit per case, when documented.

For paper anesthesia records, this requires a quick recap with the surgical team at the conclusion of each case. For electronic records, the information is typically input by the surgical tech, but should still be verified for accuracy. Either way, it’s crucial that the surgical descriptor not be populated before the procedure begins and never looked at again.


Anesthesia Start Time

Per the ASA and CMS, time begins when the anesthesia provider is in personal attendance with the patient and is preparing the patient for induction.

This does not include the pre- anesthesia assessment, which is not separately billable. However, if you are in the holding area and administer an anxiolytic 5 minutes prior to entering the operating room, this is billable time. Also, patient transfers from the ICU to the OR (or vice versa) are to be included in your billable anesthesia minutes. The takeaway here – “OR in time” does not always reflect your true anesthesia start time, which may have begun earlier.


Labor and Delivery Time

Unlike traditional surgical cases, labor time begins when the epidural is placed and ends at newborn delivery or placental delivery/episiotomy end time, when anesthesia personnel are present. The bottom line – delivery time is not always the true end time for OB cases, when charted properly.


Transesophageal Echocardiograms (TEE)

Many payers, including Medicare, will only pay for TEEs when an interpretation is documented by a physician (a certified Anesthesiologist or Cardiologist). Due to this requirement, it’s recommended that all TEE probe placement procedures include a notation of “interpretation and report by Dr. X”. Although there’s a code for TEE probe placement without a formal interpretation (93318), few insurers pay for it.


Staffing Changes

When an intraoperative hand-off occurs between anesthesia providers, it’s important to chart when the relief took place and who was involved. Failure to chart these changes can result in inaccurate concurrency ratios for medically directing practices and can skew provider productivity numbers. As an example, a planned labor and delivery is converted to a C-section, using a different anesthesia provider. If the provider change and relief time are not documented, the case will be under-billed by 1 unit and the relieving provider will get no credit for the case. Another example is a case which starts off as medically directed and is later converted to a personally performed model.


Invasive Monitoring Lines

Arterial Lines, CVPs and Swan-Ganz catheters are billed as separate surgical procedures, along with the anesthetic. Documentation needs to show who physically placed each line, when they were placed, and whether or not ultrasound guidance was utilized.Simply checking a box that the line was used during the case is not sufficient for billing purposes.

CVPs and Swans can be separately billed when there are “two separate sticks” documented, or when the Swan is placed during a subsequent time period. If a line is placed by a SRNA or Resident, documentation should state that the Anesthesiologist was physically present during the entire minor surgical procedure, if applicable.


Post-Op Pain Blocks

Acute pain blocks require 3 main documentation items: That the block was performed at the surgeon’s request, that its primary purpose was for post-op pain relief (even if it had an adjunctive benefit to the anesthetic), and whether or not ultrasonic guidance was utilized.

In addition, it should be specified who placed the block and whether the block was performed prior or subsequent to anesthesia induction. Providers should steer clear of documentation that says “block used for both anesthesia and pain management”, as this does not clarify the block’s primary intent.


Final Mode of Anesthesia

Similar to the planned surgical procedure that can change mid-stream, it’s important to document the final anesthesia type on each record that you complete.

For example, a planned MAC anesthetic that is converted to a General (defined as any loss of consciousness) should be clearly noted to avoid unnecessary denials. For example, many insurance plans have restrictive coverage policies for MAC GI Endoscopy procedures, but allow payment for Propofol General anesthetics.

 Be vigilant to ensure that the final anesthesia type is always charted.


“Shadowing” Providers

When a provider such as a SRNA is charted as being in the OR, but is there only for observation purposes, this should be noted. SRNAs and Residents have a 2-room physician oversight limit, but this is not the case if the SRNA is simply observing and has no clinical involvement in the case.


Medical Direction

Each Care Team case involving both an Anesthesiologist and an Anesthetist should include documentation showing that all 7 of the TEFRA requirements were satisfied by the Anesthesiologist. These are: ensuring the anesthetist is qualified, participation in the pre-anesthesia assessment, presence at induction and emergence, frequent monitoring, remaining immediately available, and providing indicated post-anesthesia care.

This can be done via individual or global attestations and should be time-stamped. Requirements can also be shared by different Anesthesiologists within the same group. For groups who employ their CRNAs, it’s appropriate to bill cases as “non medically directed” (-QZ) when such attestations are incomplete, as most payers still reimburse these cases at 100%.

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.