Anesthesia services guidelines updated

We’ve updated the medical record documentation requirements for anesthesia services as follows:

• To the list of facts that must be included in the “anesthesia record,” we’ve added the wording shown in bold:
  
  Route of anesthetic and medication administered (for example, IV, mask, endotracheal, laryngeal mask airway, regional)

• To the list of items the anesthesiologist’s medical record must include, we’ve added the wording shown in bold:
  
  Documentation of a pre-anesthesia evaluation of the patient within the 30-day period prior to the administration of anesthesia (including a complete history, physical examination with specific inclusion of a Mallampatti Score and notes regarding oral and dental hygiene, review of systems, personal and relevant family medical and social history, and review of pertinent diagnostic tests sufficient to document the safety of the planned surgical procedure and anesthetic)

For more information, please see the “Documentation Guidelines for Physicians and Other Professional Providers” chapter in your online provider manual. To view the chapter:

• From web-DENIS, click on BCBSM Provider Publications and Resources.
• Click on Provider Manual.
• Click on Provider Type and select yours from the “Make Selection” box.
• Click on the Search button and then on the "Documentation Guidelines for Physicians and Other Professional Providers" chapter.