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Documentation Requirements to Bill Under the Anesthesia Medical Direction Rules

Seven steps required documentation criteria:

  • Performs a pre-anesthesia evaluation
  • Prescribes the anesthesia plan
  • Personally participates in the most demanding aspects of the anesthesia plan including, if applicable, induction and emergence
  • Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified individual
  • Monitors the course of anesthesia administration at frequent intervals
  • Remains physically present and available for immediate diagnosis and treatment of emergencies
  • Provides indicated post-anesthesia care. This MUST be documented by the attending physician and is required for billing.

Documentation/Attestation for the 7th Step is required to be documented by the Anesthesiologist billing Medical Direction.  This is different than the CoP requirement for post anesthesia evaluation, which can be performed by a qualified individual eligible to administer anesthesia e.g., residents, CRNAs