Anesthesiology medical billing has specific documentation requirements that must be met for accurate reimbursement. This article highlights some of the basic rules involved

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Documentation Requirements
for Accurate Anesthesiology
Medical Billing
An anesthesiologist has a significant role to
play during a surgical procedure where he has
to continually monitor
and control a patient’s
vital parameters such as
breathing, heart rate
and rhythm, blood
pressure, body fluid
balance and body
temperature and
accordingly adjusting the amount of anesthetic
medication administered.
An anesthesiologist has to work with other
qualified medical staff such as certified nurse
anesthetists (CRNA) and anesthesia assistants
(AA). For receiving reimbursement benefits,
anesthesiologists must comply with special
documentation requirements and ensure
accurate anesthesiology medical billing.
Medicare and other insurers will reimburse only
those healthcare providers who are directly
involved in providing medical direction. The
rules pertaining to medical direction come into
play when an anesthesiologist is part of a team

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comprising one to four other qualified
providers in overlapping cases. Even a single
minute in instances where more than four
cases overlap will be regarded as medical
supervision, which will not be reimbursed. In
teaching hospitals where residents are involved
in patient care, the rules may be different.
Anesthesiology Billing – Important Points
to Note
Here are some tips that will help you handle
your challenging anesthesiology medical billing
tasks:
• The anesthesiologist must be directly
involved in taking decisions for providing
appropriate anesthetics such as regional
block, general anesthesia and monitored
anesthetic care for a surgical procedure.
• Prior to an anesthetic session, the
anesthesiologist must personally conduct
the necessary exams and evaluations.
Although there are no specific rules
regarding what must be examined or
evaluated, the specific system or body area
examined and the related findings must be
properly documented.

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• The anesthesiologist must be physically
present in the surgical room where
anesthesia is being administered and he
must provide appropriate monitoring
through the entire surgical procedure.
• The anesthesiologist must ensure that
everyone who is participating in the
anesthesia care is qualified to perform the
procedure. Providers participating in the
procedure must sign in to the case,
attaching his/her certification or license
such as MD, CRNA or AA.
• The anesthesiologist must be physically
present for highly demanding procedures
such as induction and emergence when
these are the elements of the service
provided. In case there are other
demanding aspects of the service, the
anesthesiologist must be in the room when
those services are being provided and
clearly document his/her presence and
participation.
• Any services provided during the post-
anesthesia time have to be clearly
documented. The anesthesiologist is
responsible for the patient till the time
patient care is transferred to another
caregiver.

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• Regarding documentation of monitoring, in
paper records the anesthesiologist can
initial the patient chart tracking the
patient’s vital parameters, medication
administration and other details each time
he/she enters the patient’s room to check
on the patient. In electronic records, a
statement can be added that he/she was
present for monitoring each time they
entered the room to check on the patient.
Or documentation can be made at the end
of the record that he/she monitored the
patient throughout the period the patient
was in their care.
Anesthesiology Billing Outsourcing for
Accurate Reimbursement
Busy anesthesiologists involved in different
cases at the same time could consider
outsourcing to a reliable medical billing
company compliant with HIPAA rules and
regulations. Usually, reputable companies offer
free analysis which will help identify and
address problem areas in the medical billing
process. Experienced medical billers and
coders with comprehensive knowledge of
anesthesiology medical codes and payer
policies will ensure accurate coding and

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reimbursement. These medical billing services
are offered at competitive pricing with cost
savings of 30 to 40%.