tci Medicare Compliance & Reimbursement - 2014 Issue 12

Documentation: Remember the Rules for Medical Direction

Meet these 7 criteria and you’re on your way to QY or QZ success. Before you can code medical direction for anesthesia services during surgery, the anesthesiologist must document his or her presence during all critical or key portions of the procedure. The anesthesiologist must: perform a pre-anesthesia examination and evaluation; prescribe an anesthesia plan; personally participate in the most demanding procedures of the anesthesia plan, including induction and emergence; ensure that any procedure in the plan that he or she does not perform is performed by a qualified anesthetist; monitor the course of anesthesia administration at intervals...

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