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Tag Archives: Anesthesia

New to anesthesia coding

I’ve recently started billing anesthesia claims for a ASC and I’m having trouble getting BCBS to pay these claims and of course no one at BCBS can answer my question.

Are anesthesia claims billed on a 1500 or UB 04? That’s all I need to know. I’m entering these claims on the BCBS website and something isn’t right. Not sure if I’m entering something wrong or not entering something. The only thing I can get out of BCBS is that it’s not on the correct form.

Thanks in advance for any help.

Teresa D

Medical Billing and Coding Forum – Anesthesia

Anesthesia Medical Malpractice

In the United States, medical malpractice is very common.  Anesthesia medical malpractice make up the majority of these malpractice cases, ranking twelfth highest of the medical specialties where doctors in these specialties have to pay compensation for their mistakes.  Anesthesia malpractice is life changing.  A doctor’s negligence can cause permanent damage to the brain and even death.

Even though medical malpractice is common, proving negligence with anesthesia cases against the defendant is not easy to do.  One reason is that a patient is heavily sedated, even unconscious at times, when given anesthesia.  Another reason proving doctor’s negligence is difficult is because there is little to no notes taken for a patient’s medical record during surgery.

How Can Medical Malpractice Related to Anesthesia be Avoided?

Taking thorough notes on every patient should be standard by hospitals, so any chances of anesthesia malpractice can be avoided.  Unfortunately, this is not always the case, and while the patient is under anesthesia, an error occurs.  A patient’s medical record should include:

A pre-anesthesia exam
Informed consent form
Operative record
Transfer notes
Doctor notes
Post-anesthesia record

Regrettably, there are cases when notes of a patient were taken but sadly, they were “altered” or “misplaced” to cover up their misconduct.  Malpractice insurers and professional medical societies have a duty to inform health care professionals not to alter any medical records.  Nonetheless, this professional and ethical advice gets forgotten when a mistake does occur that was life altering or even life threatening.

Where Does Medical Malpractice Happen?

It is often thought that medical malpractice with anesthesia takes place only in an operating room.  This is not the case, anesthesia mistakes can occur before surgery, after surgery, any procedure room and even in a dental office.  Any type of situation where anesthesia is given can result in malpractice, from childbirth to a simple dental procedure.

A patient can suffer many different types of problems due to this type of medical malpractice.  Some of the more common injuries a patient can suffer include:

Cerebral palsy
Brain damage
Nerve damage

How Can You be Prepared?

Most of these anesthesia malpractice cases are unintentional but not any less devastating to an individual.  It is important to be aware of these mistakes and be prepared for them.  Sharing your medical records with your doctor, anesthesiologist, and close family members is a good way to be prepared.  Make sure you and others are aware if you have any allergies or if you could have a harmful reaction before administering the anesthesia.

If you or someone you know, was a victim of an anesthesia medical mistake contact an experience medical attorney immediately.  They can evaluate your claim and will go over all of your legal options.

David Austin is an Attorney focused on complex injury cases. You can learn more about Anesthesia Medical Malpractice at his website.

Anesthesia Coding – Get the Correct Codes For Transesophageal Echocardiography

The most common problem in anesthesia coding associated with billing and obtaining reimbursement for transesophageal echocardiography or TEE is determining whether the procedure is for diagnostic or monitoring purposes. It is often difficult to tell whether the TEE was diagnostic or not unless your physician identifies the study’s purpose. If you wish to bill for a diagnostic TEE, attach a written report, or else it’s unlikely to withstand the scrutiny of an audit.

CPT contains two sets of codes for diagnostic transesophageal echocardiography or TEE. For a diagnostic test, pay attention to whether the anesthesiologist places the probe, interprets and reviews the study, or provides both services. When your anesthesiologist places the probe and does not provide a written report, use the placement-only diagnostic TEE codes. Your physician sometimes might interpret the findings while another physician places the probe. Provided your anesthesiologist is the only physician to issue a written report of the diagnostic TEE, you would code for the “image acquisition, interpretation and report” only with 93314 for real-time TEE and 93316 for TEE for congenital cardiac anomalies.

Avoid truncated diagnosis codes in anesthesia coding. Make sure your anesthesiologist is as specific as possible when reporting diagnoses attached to TEE use. Merely linking the TEE code to a payable ICD-9 code is not sufficient. Clinical signs or symptoms must be present and documented.

Transesophageal echocardiography for monitoring is never paid nor is it ever unbundled. When TEE is used in dissection or with valvular repair, your anesthesiologist is diagnosing whether surgery fixed the lesion. Your anesthesiologist is then not monitoring, but telling the surgeon whether his repair has corrected the problem to an acceptable level. Here, he is playing an active role in management and doing more than just monitoring. If you include a full report in this case, you can bill a reimbursable code like 93312 or 93314, but make sure you do not label this report as monitoring, else you’ll not be entitled to reimbursement.

Stay on top of the CPT codes with the latest updates and expert tips on anesthesia coding, by attending anesthesia coding seminars. 

Keep on updating your anesthesia coding knowledge with anesthesia coding seminars and many other medical coding audio conferences with premier coding experts, CDs, tapes and transcripts of coding training information by specialty.

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