With the advent of the new Anesthesia records, ( June 2016) our completed records function both
– as Medical documentation of care for the patient chart
– and also as the billing company charge submission
Our complete and legible charts must meet all the medical recording requirements but also be compliant with ICD 10 for successful and timely reimbursement.
Although subjective, the chart must be readable by someone who doesn’t know you. This includes carbon second copies.
Medically required elements of care must be complete.
Are carefully laid out on the record. They include; type of anesthetic (MAC, TIVA/LOC or GA); times, post –procedure diagnosis and (complete) procedure performed.
Charts are reviewed in real time by our external billing company.
1, Each of us receives regular emails from our billing company with documentation errors requiring immediate correction.
2, Tabulated results are reported to the company on a monthly basis.
During this time of transition to ICD 10 and to the new forms, we recognize the challenges involved in scoring well, however we will begin reporting results in July. By the last part of the year we expect all providers to be reliably scoring well. These later results will be included in the final 2016 performance review.
At present many of us have very large error rates – so please work at improving