What's on it
Use this to spot-check a handful of records each month. The same gaps tend to show up again and again.
Every record
- Patient, date and facility
- Procedure as performed, matching the operative note
- Anesthesia type (general, MAC, regional, neuraxial)
- Pre-anesthesia assessment
- Physical status (P1 to P6)
Time
- Anesthesia start time
- Anesthesia end time
- Any breaks in care, with times
- Handoffs between providers, with times
Staffing
- Who provided care, by name and credential
- For care-team cases, the anesthesiologist's presence at key points
Extras that are billed separately
- Post-op pain blocks: surgeon's request, block type, side, drug and guidance
- Arterial and central lines, with ultrasound documentation if used
- Any other separately billable procedures
Medical necessity
- Reason MAC was needed when payers ask for it
- Conditions that support qualifying circumstances or physical status
- Emergency details when 99140 is billed