Clarifying Post-Op Pain Documentation

Several clients have recently asked us to clarify the documentation requirements for post-op pain. Since there seems to be some confusion in this area, we thought it would be appropriate to refresh everyone’s understanding.

In order to be reimbursed for postoperative pain management services the following must be documented in the patient’s medical record/chart by the anesthesia provider:

1.    The surgeon’s request for the anesthesiologist to manage the patient’s post operative pain (normally documented on the same day of the procedure).

2.    The documentation must support going above and beyond the “normal” post anesthesia care service that is performed with every anesthesia patient.

3.    Physical exam of the patient.

4.    Patient pain score (1-10 scale is appropriate).

5.    Whether the provider has chosen to continue or discontinue the current treatment plan, which is usually based on straightforward medical decision making. Examples:

·         Patient is stable or improving.

·         Patient has minor complication or no response to current treatment.

·         Patient is unstable or new complications have developed.

6.    If treatment is discontinued, provider must document the evaluation of the patient and the decision to remove a catheter in order to be reimbursed for the date of the removal.

ARM will continue to bill based on the billing forms that are received, however please remember to document all of this information in the patient’s medical record/chart. Please contact us at clientsupport@armgmt.com if you have any questions or would like to discuss this with one of our coding specialists.