A Refresher on Documentation of Anesthesia Postoperative Evaluations
Summary
To clarify one of the more confusing issues in anesthesia, we offer an overview of the documentation requirements for and distinctions between three types of anesthesia postoperative visits: 1) Conditions of Participation; 2) anesthesia postoperative evaluation; and 3) postoperative pain follow-up evaluation..
One of the issues in anesthesia that is most confusing is postoperative visits with the patient. This eAlert presents the three kinds of postoperative visits, what is needed for documentation and when a visit is billable.
The three visits can be defined as:
Conditions of Participation
The CoP visit is required for all patients who receive anesthesia based on Joint Commission (JC) inspection guidelines. This is true if the patient is an inpatient or outpatient. This is a requirement for the institution and does not affect billing. The JC rule calls for:
A postanesthesia evaluation completed and documented by an individual qualified to administer anesthesia . . . no later than 48 hours after surgery or a procedure requiring anesthesia services.This means that either a physician, CRNA, or anesthesia assistant can do this visit. This visit is required for general, regional or MAC anesthesia. This visit does not need to be performed by the same person who administered the anesthesia. According to JC guidelines, the visit should not occur until
. . . the patient is sufficiently recovered from the acute administration of the anesthesia so as to participate in the evaluation.For patients unable to participate in the CoP postanesthesia evaluation, a postanesthesia evaluation should be completed and documented within 48 hours with notation that the patient was unable to participate and the reason why.
The following are the minimum elements that must be evaluated and documented:
Anesthesia Postoperative Visit
The anesthesia postoperative visit is the visit that is part of the seven steps of medical direction. This visit only applies to the cases where a physician is medically directing nurse anesthetists, anesthesia assistants and student nurse anesthetists. (This is not to say that a visit may not be appropriate for non-medically directed situations based on the patient's condition.) The medical direction CMS rule states that the physician "Provides indicated postanesthesia care."
The question here is what does the word "indicated" mean? This is open to interpretation. If it was required for all patients, the word indicated would not be necessary. Does "indicated" represent that the visit is not "indicated" on all patients? Does the statement mean that the visit is only needed for patients for whom a visit is clinically indicated? If this is your interpretation then the need for the visit is a clinical decision for each individual patient. It would also mean that what is assessed is a clinical decision, as there are no minimal guidelines as to what should be evaluated. This visit is included in the base units of the procedure, and is not billable separately.
Postoperative Pain Follow-up Visit
Pain follow-up visits represent a clinical decision for patients who received pre-operative, intra-operative or postoperative injections or infusions to control postoperative pain. This visit does not occur on the same calendar day as the surgery. This visit is separate from any other visit and must be medically necessary from a clinical perspective. Depending on state law and hospital policy, this visit can be performed and billed by a physician, CRNA, advanced practice nurse, or physician's assistant who is employed by the group. Your billing entity must know what the visit is being performed for (e.g., epidural, block) in order to bill with the proper code. If the visit is for a follow-up visit for an epidural catheter, your billing partner needs to know if the catheter was in place at the time of the visit.
The pain follow-up visit should document the following components based upon CPT rules:
With best wishes,
Tony Mira
President and CEO