Checklist: Anesthesia services documentation

Documentation is for the correct beneficiary.

Documentation is for the correct date(s) of service.

Documentation contains a valid and legible signature, which follows CMS Signature Guidelines for Medical Review Purposes.

Documentation contains anesthesia start and stop times.

Documentation that clearly documents the reason for the monitored anesthesia care (e.g., the patient's condition that requires the appropriate anesthesia; indications the procedure performed was deep, complex, complicated, or markedly invasive); if applicable.

Documentation supports a medically reasonable and necessary of the service(s) that includes relevant pre-procedure documentation (i.e., pre-anesthetic evaluation, history, and physical examination, etc.)

Documentation of the procedure, operative, and anesthesia reports (that show evidence of continuous monitoring of the patient's oxygenation, ventilation, circulation, and temperature; when applicable.

Documentation supports a post-anesthesia evaluation of the patient including any unusual events or complications and the patient's status on discharge.

If billing incident to services, the documentation to support appropriate supervision during the anesthesia service.

Documentation includes an advanced beneficiary notice of non-coverage was provided (if applicable and required).

Any additional documentation to support medical necessity or any applicable policy guidelines for the services billed.