Anesthesia Services
Insufficient documentation means something was missing from the medical records. Below is a list of the most common reasons CERT determined there was insufficient documentation that caused improper payments for anesthesia services:
- Missing pre-anesthesia exam
- Missing anesthesia record
- Missing post-anesthesia exam
- Missing electronic signature or legible signature of the performing provider
Pre-anesthesia exam: Documentation that a pre-anesthesia examination and evaluation was performed.
Anesthesia record: Documentation of the anesthesia care during the procedure.
Post-anesthesia exam: Documentation that a post-anesthesia evaluation was performed.
Signature: An electronic signature or legible signature is required on all notes.
Related Content
- CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 50 – Payment for Anesthesiology Services (1 MB)
- CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4 – Signature Requirements (609 KB)
Reviewed 11/14/2024