In regard to time notations, anesthesiologists should continue to chart vitals and add other time notes as the procedure ends. In order to avoid time deficiencies that CMS could audit, anesthesiologists should consistently add surgery end-time, operating room out-time and postanesthesia care unit in-time notes to their end-of-case documentation.
Regarding bundled payments, CMS lists “post-anesthesia recovery care” as integral to every anesthesia code. Mr. Mira said this includes the time anesthesiologists spend with the patient in the recovery room before transferring care.
Anesthesiologists also must include a postanesthesia assessment, which can’t begin until the patient has the ability to participate in the process.
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