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.