C. Documentation For Anesthesia Record
General Documentation Requirements for all services:
· Anesthesia services performed, including exact time spent performing anesthesia services, must be documented in the anesthesia record to support billing.
· Rendering practitioner/qualified healthcare professional must note their credentials and legibly sign and date the record.
· Member identifying information must be present on all pages of the record.
· Documentation must be legible.
Medical Direction Documentation Requirements
For each anesthesia procedure, the anesthesiologist must document that he/she performed the following seven services and record each in the patient’s anesthesia record:
1. A pre-anesthetic examination and evaluation;
2. Prescribe the anesthesia plan;
3. Personally participate in the most demanding procedures of the anesthesia plan including, if applicable, induction and emergence;
4. Ensure that any procedure in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist;
5. Monitor the course of anesthesia administration at frequent intervals;
6. Remain immediately physically present and available for immediate diagnosis and treatment of emergencies; and
7. Provide the indicated post-anesthesia care.
Medical Supervision Documentation Requirements
When the anesthesiologist does not fulfill all of the “medical direction” requirements listed above, the anesthesia services are considered medical supervision services. Documentation must indicate if the anesthesiologist was present at induction.