Our auditors have noted that while reviewing for factors that affect Medicare and Medicaid billing compliance, there are some issues of concern. Some of the surgery center anesthesia records reviewed lack elements of the required information needed to meet federal and state billing requirements. We saw records that lack a space to document the pre-anesthesia evaluation, anesthesia type or the surgical procedure. Others did not have an area to note the post-anesthetic evaluation.  The lack of these items jeopardizes the ability to bill appropriately for Medicare and Medicaid cases.

ACC recommends that our clients review the anesthesia record in order to assure it contains the documentation necessary to meet Medicare billing requirements.  If you have any questions regarding surgery center anesthesia records, please free to contact us so that we may review the records with you.