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Comprehensive Error Rate Testing

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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.

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