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Documentation Requirements for Accurate Anesthesiology Medical Billing An anesthesiologist has a significant role to play during a surgical procedure where he has to continually monitor and control a patient’s vital parameters such as breathing, heart rate and rhythm, blood pressure, body fluid balance and body temperature and accordingly adjusting the amount of anesthetic medication administered. An anesthesiologist has to work with other qualified medical staff such as certified nurse anesthetists (CRNA) and anesthesia assistants (AA). For receiving reimbursement benefits, anesthesiologists must comply with special documentation requirements and ensure accurate anesthesiology medical billing. Medicare and other insurers will reimburse only those healthcare providers who are directly involved in providing medical direction. The rules pertaining to medical direction come into play when an anesthesiologist is part of a team
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comprising one to four other qualified providers in overlapping cases. Even a single minute in instances where more than four cases overlap will be regarded as medical supervision, which will not be reimbursed. In teaching hospitals where residents are involved in patient care, the rules may be different. Anesthesiology Billing – Important Points to Note Here are some tips that will help you handle your challenging anesthesiology medical billing tasks: • The anesthesiologist must be directly involved in taking decisions for providing appropriate anesthetics such as regional block, general anesthesia and monitored anesthetic care for a surgical procedure. • Prior to an anesthetic session, the anesthesiologist must personally conduct the necessary exams and evaluations. Although there are no specific rules regarding what must be examined or evaluated, the specific system or body area examined and the related findings must be properly documented.
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• The anesthesiologist must be physically present in the surgical room where anesthesia is being administered and he must provide appropriate monitoring through the entire surgical procedure. • The anesthesiologist must ensure that everyone who is participating in the anesthesia care is qualified to perform the procedure. Providers participating in the procedure must sign in to the case, attaching his/her certification or license such as MD, CRNA or AA. • The anesthesiologist must be physically present for highly demanding procedures such as induction and emergence when these are the elements of the service provided. In case there are other demanding aspects of the service, the anesthesiologist must be in the room when those services are being provided and clearly document his/her presence and participation. • Any services provided during the postanesthesia time have to be clearly documented. The anesthesiologist is responsible for the patient till the time patient care is transferred to another caregiver.
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• Regarding documentation of monitoring, in paper records the anesthesiologist can initial the patient chart tracking the patient’s vital parameters, medication administration and other details each time he/she enters the patient’s room to check on the patient. In electronic records, a statement can be added that he/she was present for monitoring each time they entered the room to check on the patient. Or documentation can be made at the end of the record that he/she monitored the patient throughout the period the patient was in their care. Anesthesiology Billing Outsourcing Accurate Reimbursement
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Busy anesthesiologists involved in different cases at the same time could consider outsourcing to a reliable medical billing company compliant with HIPAA rules and regulations. Usually, reputable companies offer free analysis which will help identify and address problem areas in the medical billing process. Experienced medical billers and coders with comprehensive knowledge of anesthesiology medical codes and payer policies will ensure accurate coding and
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reimbursement. These medical billing services are offered at competitive pricing with cost savings of 30 to 40%.