Documentation on the Anesthesia Record in an electronic medical record (EMR) requires the same level of vigilance and level of detail as documentation on a paper Anesthesia Record. Because reimbursement for anesthesia services is based on the surgical or medical procedure, anesthesia time and any additional services provided it is imperative that the information is entered into the EMR.
Be aware that documentation in the EMR should occur contemporaneously with the service provided. For example physician presence at induction and emergence should be entered into the record at the time of presence and not before or afterwards. The documentation is time stamped in the record and clearly indicates the time the acknowledgement was entered into the EMR.
Pre-recording information in the EMR could place into question the physician’s actual presence at the event. This could impact payment for anesthesia services reimbursed at the medically directed rate. It is important when administering regional blocks for post-operative pain management to indicate the time the block was placed which is usually before the start of anesthesia time and to document the medical necessity for the pain procedure, i.e. “surgeon requested that anesthesia administer a block for post-operative pain.” When the regional technique is used for the primary anesthetic it is necessary to record the start and stop time for the block placement, which can be used as a component of discontinuous time for reimbursement.
Documentation of provider names and times for those covering for lunch breaks and relief is also important for legal and reimbursement reasons. If a case is performed under medical direction and the CRNA is relieved by an anesthesiologist prior to emergence, the relief time documentation will assist in the determination of what modifiers to use when submitting the claim.
While the EMR solves the problem of submitting records with illegible signatures to the CMS it does not absolve the duty to provide detailed information on the care and services that were rendered to the patient.