Anesthesiologists are assuming a broader role in the perioperative setting and may have an opportunity to bill for clinical services not usually found in the anesthesia codes.  The requirements for these services usually fall under the Evaluation and Management Codes (E/M codes).  When using the E/M codes it is important to differentiate these services from those included as part of anesthesia services.

The E/M codes consist of three basic elements that must be documented to determine the level of reimbursement. The key elements are the history, physical exam and decision-making required by the patient’s condition. It is important that the level of service and all elements are documented according to the Clinical Procedural Terminology (CPT) guidelines and the patient’s condition.  One must remember that reimbursement is not dependent on how you feel about the case but on what you document in the medical record.
We will be discussing these key elements individually in our next few newsletters and show you how to pick the correct code for reimbursement.  Please stay tuned.