Anesthesia Service Information Window

This procedure enables you to document information about the case and potentially add modifiers for the type of anesthesia, physical status of the patient, and medical direction. If your selection results in a modifier being added to a charge, then the modifier is applied to all anesthesia charges on the encounter. You can also add additional procedures to the encounter from this window.

To add modifiers to all anesthesia services on an encounter, do the following:

On the Charge Posting window, enter and Save an Anesthesia charge.
Select the Anesthesia Service Information button on the charge posting toolbar.
The Anesthesia Service Information window opens.

Use the following table to select and apply modifiers to an encounter and then select OK.

Field	Description
Type of Anesthesia	Select one of the following options to identify the method of anesthesia administered: <none> QS – Monitored Anesthesia Care (MAC) 8: G8 – MAC for complicated or invasive surg 9: G9 – MAC for severe cardio-pulmonary cond General Anesthesia Epidural Anesthesia Spinal Anesthesia Note: Selection of QS, G8, or G9 will populate the modifier in position 2 for the anesthesia charges. All other modifiers are for case documentation purposes.
Physical Status	The physical status modifier is a two-character code that indicates the general health of the patient. The first character is a P and the second character is a single digit from 1-6. This selection overwrites any manually entered physical status modifier for this patient. Choose one of the following options to populate the modifier in position 3 for the anesthesia charge: <none> 1: P1 - A normal healthy patient. 2: P2 - A patient with mild systemic disease. 3: P3 - A patient with severe systemic disease. 4: P4 - A patient with severe systemic disease that is a constant threat to life. 5: P5 - A moribund patient who is not expected to survive without the operation. 6: P6 - A declared brain-dead patient whose organs are being removed for donor purposes.
Medical Direction	The purpose of this field is to override the automatic calculation performed by the concurrency audit for medical direction. The best practice is to leave this field blank or select None. Encounter failure (marked in red) occurs if: The level of concurrency selected is different from what the audit would calculate. AND The Exempt from Concurrency check box is not selected. Encounter will pass the concurrency audit and override the automatic selection of medical direction calculated by the system, if you: Select the Exempt from Concurrency check box. AND Select one of the following options: Personally performed by Physician 1 case: Medical direction of 1 case Direction: Medical direction by a Physician Supervision: Medical supervision CRNA service without medical direction Medically necessary
Present at Induction	Select this check box to indicate that the MDA was present at the initial administration of the anesthesia and when the anesthesia began to take effect.
Exempt from Concurrency	Select this check box to do the following: Exclude the providers on this encounter from being included in the concurrency calculation. Display the message Manually exempt from Concurrency on the Concurrency Audit Report for the encounter.

Anesthesia Service Information Window

To add modifiers to all anesthesia services on an encounter, do the following:

On the Charge Posting window, enter and Save an Anesthesia charge.
Select the Anesthesia Service Information button on the charge posting toolbar.
The Anesthesia Service Information window opens.

Use the following table to select and apply modifiers to an encounter and then select OK.

Field	Description
Type of Anesthesia	Select one of the following options to identify the method of anesthesia administered: <none> QS – Monitored Anesthesia Care (MAC) 8: G8 – MAC for complicated or invasive surg 9: G9 – MAC for severe cardio-pulmonary cond General Anesthesia Epidural Anesthesia Spinal Anesthesia Note: Selection of QS, G8, or G9 will populate the modifier in position 2 for the anesthesia charges. All other modifiers are for case documentation purposes.
Physical Status	The physical status modifier is a two-character code that indicates the general health of the patient. The first character is a P and the second character is a single digit from 1-6. This selection overwrites any manually entered physical status modifier for this patient. Choose one of the following options to populate the modifier in position 3 for the anesthesia charge: <none> 1: P1 - A normal healthy patient. 2: P2 - A patient with mild systemic disease. 3: P3 - A patient with severe systemic disease. 4: P4 - A patient with severe systemic disease that is a constant threat to life. 5: P5 - A moribund patient who is not expected to survive without the operation. 6: P6 - A declared brain-dead patient whose organs are being removed for donor purposes.
Medical Direction	The purpose of this field is to override the automatic calculation performed by the concurrency audit for medical direction. The best practice is to leave this field blank or select None. Encounter failure (marked in red) occurs if: The level of concurrency selected is different from what the audit would calculate. AND The Exempt from Concurrency check box is not selected. Encounter will pass the concurrency audit and override the automatic selection of medical direction calculated by the system, if you: Select the Exempt from Concurrency check box. AND Select one of the following options: Personally performed by Physician 1 case: Medical direction of 1 case Direction: Medical direction by a Physician Supervision: Medical supervision CRNA service without medical direction Medically necessary
Present at Induction	Select this check box to indicate that the MDA was present at the initial administration of the anesthesia and when the anesthesia began to take effect.
Exempt from Concurrency	Select this check box to do the following: Exclude the providers on this encounter from being included in the concurrency calculation. Display the message Manually exempt from Concurrency on the Concurrency Audit Report for the encounter.

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