Deciphering the Anesthesia Record. By: Judy A. Wilson, CPC, CPCO, CPPM, CPB, COC, CPC-P, CANPC,CPC-I

Transcription

1 Deciphering the Anesthesia Record By: Judy A. Wilson, CPC, CPCO, CPPM, CPB, COC, CPC-P, CANPC,CPC-I

2 Disclosure This presentation is intended to provide basic educational information regarding coding/billing for anesthesia and not intended to convey coding advice and does not represent the following: Official policy of the ASA (American Society of Anesthesiologists) Official policy of the Virginia CMS Every effort has been made to ensure the information in this presentation is accurate.

3 Documentation Is Key To Good Care Three must haves on all Anesthesia Records 1. Pre-Operative Documentation 2. Intra- Operative Documentation 3. Post-Operative Documentation

4 Procedure Summary Date/Time: 11/02/ Pre- Operative Documentation Procedure: EP DEV IMP IV ICD CIU CARDIAC Location: Hospital EP LAB Plan: MAC ASA Physical Status Classification: PS-4 Severe systemic disease that is constant threat to life Airway Modified Mallampati Score: II Airway Evaluation: Potential difficult A/W by exam/hx Dentition: Abnormal and Risk of dental injury discussed Beta Blocker: Patient on beta-blocker prior to admission. Patient given beta-blocker during perioperative period. NPO Status: Confirmed NPO Review of Systems: Review of systems per medical, surgical and social history, Sleep Apnea: No Good functional capacity MET level 4 or more: No

5 Pre-Operative Documentation Continued: Personal and Family Anesthesia History: no anesthetic complications NPPhysical Exam: Heart: Regular rate/rhythm Lungs: Clear to auscultation EKG: EKG abnormal, per chart CXR: CXR abnormal, per chart Pregnancy: Denies, No LMP recorded. Patient is postmenopausal. Allergies: Penicillin Reactions: hives Past Medical History: Shortness of breath, Heart murmur, Congestive heart failure, Unspecified, community acquired pneumonia, unspecified deficiency anemia, Fast heart beat, Vision decreased (glasses), Post-menopausal History: Substance Use Topics: Smoking Status, Never Smoker; Smokeless tobacco, Never used; Alcohol Use: No History reviewed. No pertinent past surgical history.

6 Pre-Operative Documentation Continued: I have informed patient of his/her guardian of the nature and purpose of the type of anesthesia, the reasonable alternative anesthetic methods, pertinent foreseeable risks involved and the possibility of complication. I have explained that an alternative form of anesthesia may be required by unexpected conditions arising before or during the procedure. Patient or his/her guardian understand that general anesthesia may be required for his/her safety or comfort. Questions have been answered to the satisfaction of patient or his/her guardian who accepts the risk and agrees to proceed as planned. The above anesthetic review of patient s medical history, exam, tests, assessment subsequent anesthetic pain and consent have been accomplished pre-procedure. Physician signature.

7 ASA Status Must be Documented on all Anesthesia Charts Physical Status 1 A normal healthy patient Physical Status 2 A patient with mild systemic disease Physical Status 3 A patient with severe systemic disease Physical Status 4 A patient with severe systemic disease that is a constant threat to life Physical Status 5 A moribund patient who is not expected to service without the operation Physical Status 6 - A declared brain-dead patient whose organs are being removed for donor purposes These definition can be found in every edition of the ASA Relative Value Guide

8 Documentation Intra- Operative Monitored Anesthesia Care Sedation Moderate, Conscious, Deep Regional Anesthesia Spinal, Epidural, Nerve/Plexus Block General Anesthesia ETT (Endotracheal intubation), LMA (Laryngeal mask airway), Mask (Use of a Mask to introduce the anesthetic), TIVA (Total Intravenous anesthesia)

9 Documentation of Position Can Increase Payments Positions PRONE SUPINE LITHOTOMY FIELD AVOIDANCE LATERAL DECUBITUS

10 Field Avoidance Any procedure around the head, neck or shoulder girdle, requiring field avoidance, or any procedure requiring a position other than supine or lithotomy, has a minimum Basic Value of 5 regardless of any lesser basic value assigned to such procedure in the body of the Relative Value Guide

11 Documentation of Lines and TEES Arterial Line (Art. Line Central Line (CVP Line) Pulmonary artery catheter (Swan Ganz/PAC) Transesophageal echocardiogram (TEE) Procedure done by Anesthesiologists

12 ANESTHESIA RECORDS Procedure Summary Date: 11/02/15 Responsible Provider: Dr. AAPC Location: Hospital EP LAB Procedure [code] HEART CARTHETERIZATION BIV ICD Diagnosis [codes] CAD Staff Role Begin End Name: Dr. AAPC ANEST Antibiotic Verified /2/2015 Antibiotic Yes Given w/in 60 min of incision Events Date: Time Event Last Edited 11/2/ Ready for 11/2/15 Dr. AAPC Procedure Anesthesia 11/2/15 Dr. AAPC Start 0728 Dr. AAPC 0728 Start Data 11/2/15 Dr. AAPC Collection 0728 Dr. AAPC 0733 Induction 0807 Dr. AAPC Patient was identified and procedure verified. The most recent ASA Guidelines were utilized for preanesthesia machine/equipment checkout. SpO2 and other appropriate alarms are active. Patient was re-evaluated immediately before starting the induction/procedural sedation and determined to be clinically ready for planned anesthetic and surgery.

13 Documentation for Lines Procedure Epidural Placement at the request of the Surgeon for Post-Op Pain CT Anesthesia Epidural Placement Note IV access present, noninvasive monitors applied. Patient place in sitting position. Thoracolumbar sterile pre and drape. 1% lidocaine infiltration #17 G Tuohy place in T6-T7 epidural space via loss of resistance technique employing Air after 1 attempt(s). Epidural catheter: 3cm of catheter in epidural space Test Dose: Lidocaine 1.5% with 1.200k Epinephrine 3 ml. Medication: APF Morphine 5mg Infusion medication: Fentanyl 2 microgram/ml, Bupivacaine 0.125% in 100ml NSS Comment. Vital signs stable after procedure finished. Dr. Goofy

14 Documentation of Epidural Follow Up Author: Dr. Good Service: Anesthesiology Author Type: Physician Filed: 11/09/2015 Note Time: 11/09/ Status: Signed Editor Mickey Good, MD (physician) Epidural Follow Up Note Pain Level: Pt denies Nausea: No Pruritus: No Condition of insertion site: OK Medication: Fentanyl 2 microgram/ml, Bupivacaine 0.125% in 100ml NSS First Chest tube removed yesterday. Final chest tube to be removed today. Plan: discontinue epidural: catheter removed with tip intact

15 Documentation of Arterial Line (ART LINE) Arterial Line Start time: 10/1/2015 7:51 AM End time: 10/1/2015 7:54 AM Reason: at surgeon's request and intra operative anesthesia Procedure Note: Arterial line insertion Indication: continuous hemodynamic monitoring Informed consent obtained. Sterile prep & drape. 1% lidocaine infiltration. 18 Gauge catheter placed in left radial artery via sterile technique

16 Documentation of Central Lines Central Line Start time: 10/1/2015 8:11 AM End time: 10/1/2015 8:21 AM Reason: at surgeon's request and intra operative anesthesia Patient identified. Consent obtained. Patient transferred to cardiac OR 2. Standard ASA monitors applied. Pre-oxygenation. Arterial line placed per anesthesia record. Induction per anesthesia record. Endotracheal intubation per anesthesia record. Patient placed in Trendelenburg position for central venous catheter (CVC) placements and pulmonary artery catheter placement. Universal Protocol completed/time-out conducted prior to central line insertion Prep and technique per CDC protocol. Dynamic ultrasound guidance was not employed. The image(s), if applicable, were placed in the chart. CVC #1: 4 lumen 8.5 French catheter: Placed in Right internal jugular vein. All ports aspirated and flushed. Sutured. Dressed after surgery completed. Indications: Need/potential for vasoactive infusions; need for multiport access; need for secure, reliable intravenous access; and surgeon requests for postoperative use. CVC #2: 9 French introducer. Placed in Right internal jugular vein using a separate site. Catheter aspirated and flushed. Sutured. Dressed after surgery completed. Pulmonary artery catheter: Flushed. Balloon checked. Distal port flushed when placed in introducer. Floated easily after chest open. Indications: Cardiac Output/Index; hemodynamic parameters (stroke volume, systemic vascular resistance, etc.); measurement of pulmonary artery pressures; and surgeon requests for postoperative use. Medicare PQRI Cap gv YES Mask gv YES Sterile gown gv YES Sterile gloves gv_ YES Hand hygeine gv_ YES Antiseptic prep gv_yes Large sterile drape_gv_yes

17 Documentation for Transesophageal Echocardiography (TEE) TEE at Request of the Surgeon TEE probe passed, single atraumatic attempt Patient identified. Consent obtained. Patient transferred to cardiac OR 3. Standard ASA monitors applied. Pre-oxygenation. Arterial line placed per anesthesia record. Induction per anesthesia record. Endotracheal intubation per anesthesia record. Patient placed in Trendelenburg position for central venous catheter (CVC) placements and pulmonary artery catheter placement. Unable to pass wire into right internal jugular vein; no PA catheter placed. Possible carotid puncture with seeker needle without hematoma formation Universal Protocol completed/time-out conducted prior to central line insertion Prep and technique per CDC protocol. Dynamic ultrasound guidance was not employed. The image(s), if applicable, were placed in the chart. CVC #1: 4 lumen 8.5 French catheter: Placed in Right external jugular vein. All ports aspirated and flushed. Sutured. Dressed after surgery completed. Indications: Need/potential for vasoactive infusions; need for multiport access; need for secure, reliable intravenous access; and surgeon requests for postoperative use.

18 Anesthesia Record Continued: Assessments /2/ /2/ /2/ /2/ EKG NSR;Bundle NSR;Bundle NSR;Bundle NSR;Bundle branch branch branch branch block block block block O2 room air simple face simple face simple face Device mask mask mask 11/2/ /2/ /2/ EKG NRS; Bundle NSR; Bundle NSR; Bundle blanch block blanch block blanch block O2 Simple face Simple face Simple face Device mask mask mask 0753 Antibiotic11/2/2015 DR. AAPC Verified 0756 DR. AAPC 0755 Procedure 11/2/2015 DR. AAPC Start 0807 DR. AAPC 0756 Position 11/2/2015 DR. AAPC 0756 DR. AAPC 0813 Quick Note 11/2/2015 DR. AAPC 0817 Dr. Mickey informs that air may have been entrained. Mild hypoxemia expected 0853 Emergence 11/2/2015 DR. AAPC Stop Data 11/2/2015 DR. AAPC Collection Anesthesia 11/2/2015 DR. AAPC Stop 0911

19 Anesthesia Record Continued: Lines, Drains, and Airways Type Details Placement Removal PIV Location Left, 02/7/ /3/ Antecubital; Size by RN By RN 20 gauge; Pre- existing No PIV Location Rt 11/2/ / Antecubital; Size RN RN 20 gauge; Preexisting No Positioning Position Arm 11/2/ Supine Bilat arms tucked Position Checklist 11/2/ Anesthesia Check list Anesthesia machine/airway per latest ASA guidelines, as indicated; Audible, Alarms On; Pulse oximeter, EKG, Gas, Analyzer ETCO2;O2 analyzer, Gas humidifier; Infusion pump; Anesthesia apparatus checked. NIPP Site Arm L Temp Src Available

20 Anesthesia Record Continued: Case Tracking Events Event Time In Anesthesia Interview Complete Mon Nov.2, Setup Complete-Room Ready In Room Procedure Start Procedure End Out of Room PACU in

21

22 Post Anesthesia Note Patient is recovering from his/her anesthesia His/her most recent vital signs are: Temp: 37 C (98.6 F), Pulse 82, Resp: 21, BP; 152/89 mmhg, BP Mean: 110 MM HG SpO2: 100% His/her airway is patent. He/she is awake and can follow commands after her anesthetic. Her pain is adequately controlled. Her vital signs indicate adequate postoperative hydration. PONV is not clinically significant. Healthcon, MD

23 Reading the Anesthesia Records V = systolic ^ = diastolic X = MAP (Mean Arterial Pressure) O = respiratory rate O filled in all dark = heart rate Generally if more than 70 mg of propofol given at one time it becomes a GA or General Almost all inductions for GA (General) use IV propofol or etomidate

24 Anesthesiologist A.K.A. THE PAIN FIGHTER EASING YOUR PAIN THAT S WHAT THEY DO. DEDICATED TO TAKE YOU ON A WONDEROUS RIDE AND BRING YOU BACK HOME AGAIN.

25 CASE # 1 Procedure Summary Procedure Thoracic Ascending Aorta Graft and ARR With Bypass ASA PS-4 Severe systemic disease that is a constant threat to life Pre op diagnosis: Aneurysm Post op diagnosis: Aneurysm Name Role Begin End Dr. Judy Anesth Assessments Sinus bradycardia Device: Simple face mask Device: Ventilator Events Date Time Event Edited Last 11/5/ Ready for procedure Anesthesia start Start Data Collection Induction Intubation Quick Note 0919 Procedure Note: Central Line Insertion Indication: Need/potential need for vasoactive infusions. Need for secure, reliable IV access and at the Surgeons, Dr. Dman requested placement for postoperative use. Universal Protocol prior to Central Line Insertion and PAC Placement. Informed consent obtained. Sterile pre-op & drape. Rt. Internal jugular vein Quadruple lumen catheter place via sterile Seldlngar technique employing cook needle without incidental carotid puncture. Medicare PQRS Cap YES Mask YES Sterile grown YES Sterile gloves YES Hand hygiene YES Antiseptic prep YES Large sterile Drape: YES

26 Case # 1 Continued: Procedure Note: Swan-Ganz Catheter Insertion Indication: Cardiac Output/Index. Hemodynamic parameters. Measurement of pulmonary arterial pressures and Surgeon requests placement for postoperative use. Informed consent obtained. Sterile prep & drape. Rt internal jugular vien 9.0 French introducer sheath place via sterile seldlnger technique employing cook needle w/o incidental carotid puncture. Sean-Ganz (PAC) catheter floated to position in pulmonary artery.

27 CASE # 1 CONTINUED EVENTS CONTINUED 0845 Quick Notes 0920 Well lubricated TEE was placed on first attempt with gentle pressure w/o difficulty Antibiotic Verified 0852 Procedure Start 1000 CV Bypass Initiated 1011 Quick Note: Ice bags place around head Protective goggles place over eyes 1018 Quick Note: 1025 Aortic Clamp On EVENTS CONTINUED 1027 Quick Note: 1040 Aortic Clamp Off 1153 Defibrillation 1208 Active Warming 1247 CV Bypass Ended 1410 Quick Note: Factor VII ½ dose 1518 Quick Note: requested the second half of a Factor VII dose 1522 Quick Note: TEE was removed w/o difficulty. An OG tube was placed easily. Clear gastric aspirate was obtained Stop Data Collection 1529 Anesthesia Stop

28 Anesthesia Records CASE # 1 1. What is the anesthesia start time? 2. What type of anesthesia was use? 3. What lines were placed and why? 4. Was a TEE done? 5. Was the patient on bypass? 6. What time did the patient go on bypass? 7. What time was the patient taken off of bypass? 8. What time did anesthesia stop? 9. Was there info in the chart to bill out your PQRS? 10.What PS status was this patient?

29 CASE (1) ANSWERS ANSWERS 1. START TIME 07:30 2. General Simple Face Mask 3. Central Line, Swan Ganz 4. Yes 5. YES ANESWERS 6. 10: : :44 9. YES FOR CVP 10. PS - 4

30 CASE TWO CONTINUED: Procedure Notes Last edited 11/02/ Dr. Tracy TEE Tee probe passed, single atraumatic attempt Patient identified. Consent obtained. Pt. transferred to cardiac OR3. Standard ASA monitors applied. Pre-oxygenation. Arterial line place per anesthesia record. Induction per anesthesia record. Endotracheal intubation per anesthesia record. Pt. place in trendelenburg position for central venous catheter (CVC) placement. Universal Protocol completed/time-out conducted prior to central line insertion Prep and technique per CBC protocol. Dynamic ultrasound guidance was not employed. The image(s), if applicable, were placed in the chart. CVC #1: 4 lumen 8.5 French catheter: Place in left internal jugular vein. All ports aspirated and flushed. Sutured. Dressed after surgery completed. Indications: Need/potential for vasoactive infusions; need for multiport access; need for secure, reliable intravenous access, and surgeon requests for post operative use. Medicare PQRS; CAP YES, MASK YES, STERILE GOWN YES, STERILE GLOVES YES; HAND HYGEINE YES; ANTISEPTIC PRE YES, LARGE STERILE DRAPE YES.

31 Anesthesia Record Case # 2 1. What is the anesthesia start time? 2. What type of anesthesia was use? 3. What lines were placed and why? 4. Was a TEE done? 5. Was the patient on bypass? 6. What time did anesthesia stop? 7. Was there info in the chart to bill out your PQRS? 8. What PS status was this patient?

32 CASE # 3 Procedure Summary Procedure: Pericardial Window (33025) Transesophageal Echocardiography (93312) ASA PS-4 Severe systemic disease that is a constant threat to life emergent Pre-op diagnosis: Pericardial effusion Post-op diagnosis: Pericardial effusion Name Role begin end Dr. Eric ANESTH ASSESSMENTS Sinus tachycardia Partial rebreather mask Ventilator Anesthesia: General Events Date Time Event Last Edited 10/30/ Anesthesia start Start Data Collection Patient was identified and procedure verified. The most recent ASA Guidelines were ultilized for pre-anesthesia machine/equipment checkout. SpO2 and other appropriate alarms are active. Pt. was re-evaluated immediately before starting the induction/procedural sedation & determined to be clinically ready for planned anesthetic and surgery Intubations 1548 Antibiotic Verified 1548 Active Warming Device Used 1552 Procedure Start

33 CASE 3# CONTINUED: 1623 Stop Data Collection 1636 Report Given 1639 Anesthesia Stop TEE Reason: At surgeon s request and intra operative anesthesia. Well lubricated probe place atraumatically without resistance on first attempt. Finalized, electronically signed & saved. Central Line Reason: At surgeon s request and intra operative anesthesia. Patient identified. Consent obtained. Patient transferred to cardiac OR 2. Standard ASA monitors applied. Preoxygenation. Induction per anesthesia record. Endotracheal intubation per anesthesia record. Patient place in Trendelenburg position for central venous catheter (CVC) placements and pulmonary artery catheter placement. Universal protocol completed/timeout conducted prior to central line insertion Pre and technique per CDC protocol. Dynamic ultrasound guidance was not employed. The image(s), if applicable, were place in the chart. CVC #1 4 lumen 8.5 French catheter: Place in Rt. Internal jugular vein. All ports aspirated and flushed. Sutured. Dressed after surgery completed. Indications: Need/potential for vasoactive infusions; need for multiport access; need for secure, reliable intravenous access, and surgeon requests for postopertative use

34 CASE # 3 CONTINUED: MEDICARE PQRS CAP MASK STERILE GOWN STERILE GLVOES HAND HYGEINE ANTISEPTIC PREP LARGE STERILE DRAPE YES YES YES YES YES YES YES

35 Anesthesia Record Case # 3 1. What is the anesthesia start time? 2. What type of anesthesia was use? 3. What lines were placed and why? 4. Was a TEE done? 5. Was the patient on bypass? 6. What time did the patient go on bypass? 7. What time was the patient taken off of bypass? 8. What time did anesthesia stop? 9. Was there info in the chart to bill out your PQRS? 10.What PS status was this patient?

36 Thank You for Attending