Chronic Kidney Disease (CKD) Staging

A patient with a creatinine of 2.2 is documented as having "Renal Insufficiency." To optimize CDI, the provider should:

Dental Injury during Airway Management

A tooth is dislodged during a difficult intubation. For the coder to assign T88.59 (Other complications of anesthesia), the provider must:

Medical Necessity for Specialized Monitors

A Swan-Ganz catheter is placed for a routine knee replacement. Auditors will look for:

Ultrasound Guidance for Vascular Access

Using ultrasound to place a central line is billable only if:

Extreme Age (99100) Parameters

A 70-year-and-one-day-old patient undergoes surgery. Is the +99100 code applicable?

Sleep Apnea and Surgical Risk

Documenting "Obstructive Sleep Apnea (OSA)" rather than "Snores" is essential because:

The Teaching Anesthesiologist Modifier (GC)

When a resident performs part of the procedure under direction, the modifier GC indicates:

Post-Op Pain Management: Epidural Placement

A surgeon requests an epidural for post-op pain management on a patient receiving general anesthesia. Documentation must include:

ype 1 Diabetes and Ketoacidosis

A Type 1 diabetic patient presents in DKA for surgery. To maximize CDI, the record must specify:

The Specificity of Atrial Fibrillation

A patient with long-standing persistent atrial fibrillation presents for surgery. The record merely states "History of Afib." This is problematic for CDI because:

Labor Epidural Management Units

Reimbursement for labor epidurals is often calculated differently. In many contracts, the first hour is allowed:

PACU Relief and Intraoperative Hand-offs

Documentation must show when relief took place and who was involved. Failure to chart these changes results in:

Alcohol Withdrawal Delirium (Delirium Tremens)

In the ICU post-op, a patient becomes tachycardic and tremulous with hallucinations. Documenting "Delirium Tremens" is critical because:

Anaphylaxis to Anesthesia Drugs

A patient develops hives and bronchospasm after induction with rocuronium. Documenting "Anaphylactic shock due to anesthesia" rather than "Allergic reaction" is important because:

Peripheral Nerve Injury from Positioning

A patient has a brachial plexus palsy after surgery in the Trendelenburg position. The note must document:

Discontinuous Time in Anesthesia

A surgery is delayed for 90 minutes after the patient is prepared but before induction begins. The provider leaves. The record should show:

Chronic Obstructive Pulmonary Disease (COPD) with Exacerbation

An anesthesiologist notes a patient has increased wheezing pre-op. Documenting "COPD with acute exacerbation" is better than "COPD" because:

Post-Anesthesia Hypothermia (T88.51)

A patient arrives in PACU with a temperature of 34.5°C. This is documented as a complication if:

The "Pathology Rule" Conflict

The pathology report shows "Adenocarcinoma," but the discharge summary says "Mass." For the anesthesia record, the provider should:

Meconium Aspiration Syndrome

A newborn has respiratory distress and meconium-stained fluid is present. The record must explicitly state:

Post-Dural Puncture Headache (PDPH) Specificity

To code a positional headache after an epidural as a complication, document:

Shock Due to Anesthesia (T88.2)

A patient experiences profound hypotension and circulatory collapse immediately following a spinal block. The record should state:

Anaphylaxis to Anesthesia Drugs

A patient develops hives and bronchospasm after induction with rocuronium. Documenting "Anaphylactic shock due to anesthesia" rather than "Allergic reaction" is important because:

Defining the Emergency (99140)

When a patient has a "STAT" C-section for fetal bradycardia, the provider should use the +99140 code. To defend this in an audit, the note must state:

Transesophageal Echocardiography (TEE) Interpretations

To bill code 93312 for TEE, the physician's record MUST include:

Conversion from MAC to General Anesthesia

If a MAC case is converted to General Anesthesia (GA) due to a loss of patient responsiveness, the provider must:

Canceled Surgery After Induction

If a surgery is canceled due to a plumbing leak after the patient is asleep, the provider should bill:

Encephalopathy vs. Altered Mental Status (AMS)

Post-operatively, a patient is confused and lethargic. Terminology for CDI should be:

Neonatal Sepsis Specificity

For a 10-day-old infant with sepsis, the correct code is from the:

The Linkage of Demand Ischemia

Following a stressful induction, a patient with clean coronaries has a troponin elevation and ST-depression. The correct terminology for CDI is:

MAC Necessity: The "Readiness to Convert" Rule

In a MAC record, documenting "Continuous monitoring of oxygenation and ventilation" is required because:

Failed Moderate Sedation (T88.52)

When moderate sedation fails and the patient must be intubated for the procedure, document:

Acute Kidney Injury (AKI) Criteria

A patient’s creatinine rises from 0.8 to 1.6 post-operatively. The provider should document:

Procedural Modification and Base Units

A diagnostic arthroscopy is converted to a medial meniscectomy. The anesthesia base units:

Specifying Obesity Beyond the BMI

A patient has a BMI of 42. For the coder to assign the correct high-weight diagnosis code, the anesthesiologist must:

Pediatric BMI > 95th Percentile

For a 12-year-old child, documenting "Obesity" requires:

Tobacco Use vs. Nicotine Dependence

A patient smokes a pack a day. Documenting "Nicotine Dependence" is superior to "Smoker" because:

Capturing Heart Failure Acuity

When documenting a patient with congestive heart failure (CHF) for an ASA IV classification, the provider must specify:

METs and Cardiac Clearance

A patient undergoing thoracic surgery can climb 5 flights of stairs. Documenting "VO2 max > 20 ml/kg/min" or "High METs" is essential for:

Sick Sinus Syndrome vs. Bradycardia

A patient has a preoperative heart rate of 38 and is scheduled for a pacemaker under MAC. Documenting "Sick Sinus Syndrome" is superior to "Bradycardia" because:

The "Seven TEFRA Rules" for Care Teams

Which of the following is NOT a TEFRA requirement for medical direction?

Acute Respiratory Failure (Post-Procedural)

A patient cannot be extubated and remains on a ventilator in the ICU post-op. Documentation should specify:

Malnutrition: The Missed MCC

In a patient with cancer and visible muscle wasting, the anesthesiologist should query the dietitian's notes to document:

Unintended Awareness Under General Anesthesia

A patient reports explicit recall of intraoperative events. The specific code for this is:

Malignant Hyperthermia (MH) Crisis

The ICD-10 code for MH is T88.3. To clinically validate this diagnosis in a chart, the anesthesiologist should document:

Invasive Monitoring: The "Who and How"

An SRNA (Student Registered Nurse Anesthetist) places an arterial line. To bill for this, the anesthesiologist’s note must state: