Ever wonder how cirrhosis coding affects your hospital’s HCC risk-adjustment? In this quick excerpt, I explain how accurate liver failure coding gets missed, how it impacts HCC capture, and how to get physicians and coders speaking the same language

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Has everyone forgotten about our anesthesiologists?

I rarely hear them discussed in CDI circles. A search of my favorite documentation podcasts turned up...nothing. Not a single episode.

(If I missed one, share it in the comments on the web version of this newsletter!)

Anesthesiologists are rarely queried, which means they’ve largely flown under the CDI radar.

But it’s time we gave them some attention.

The Elephant in the Room

I have to admit: no provider wants us reviewing their documentation. It may mean more work or a change in workflow…and sometimes they’re not wrong.

But gone are the days when physicians could ignore the financial and legal implications of their notes. The eye of Sauron - I mean CDI - now gazes upon anesthesiology. But with a good team, the shift doesn’t have to be painful.

What I'm Not Talking About: Professional Billing

I won’t go deep into professional billing requirements here. Anesthesiologists tend to have a solid handle on that. Their work is repetitive, time-based, and often well-templated.

Still, for the uninitiated, anesthesia documentation typically includes:

• Pre-operative (or pre-anesthesia) evaluation

• Intraoperative record

• Post-anesthesia care documentation

My focus today is on that pre-anesthesia evaluation and why it matters for CDI and risk adjustment.

Why the Pre-Anesthesia Note Matters

Anesthesiologists assess the patient holistically, not just for surgical suitability, but for how the patient’s comorbidities may impact the anesthesia plan.

And if you’ve read anything I’ve written before, you know that “comorbidities” is a magic word.

The documentation of comorbidities are not only important for reimbursement reasons, but also the growing importance of risk-adjustment.

A Quick Refresher: Risk Adjustment

Risk adjustment ensures providers aren’t penalized for caring for sicker patients. Many hospital and provider quality metrics account for illness burden, using submitted ICD-10 codes as their basis.

But those codes can only come from documentation and only if it’s codable.

Here’s what that means:

• Diagnoses must be spelled out (e.g., “hypokalemia” not “low potassium”)

• Diagnoses can only be coded from that encounter (So “rest of medical history per EMR” aint cuttin the mustard)

• Diagnoses cannot be coded from auto-generated problem lists

• Diagnoses typically require documentation of some form of M.E.A.T (Monitor, Evaluate, Assess, or Treat)

• Information in the EMR can be used to clarify, but not code, some diagnoses. Example: A coder cannot code a BMI without an associated “nutritional diagnosis” such as obesity. If obesity is documented, then the coder can go to the EMR or non-provider documentation to capture the BMI.

Why Anesthesia Notes Matter (More Than You Think)

In short-stay surgical inpatients, there may only be two physicians documenting in the medical record:

1. The surgeon – whose notes typically only focus on the surgical issue (unless they’ve been involved with CDI-initiatives)

2. The anesthesiologist – a bit more aware of, and more in the habit of documenting, additional comorbidities.

That makes anesthesia documentation critical to capturing comorbidities for accurate coding, especially when the surgeon’s note is limited.

Plus, the patient is likely in and out of the hospital before a CDI professional can review the chart.

But there’s a problem…

What I Found in an Audit

In a recent review of our anesthesia documentation, I found:

• Nonspecific terminology: Examples such as “BMI > 40,” “CHF,” “cardiac arrhythmia.” Those are effectively worthless in terms of coding and risk-adjustment.

• Key diagnoses missing or too vague: “Chronic renal dysfunction” instead of “ESRD” (an MCC!)

• Lack of connection between comorbidities and the anesthesia plan as the comorbidities were listed under a “review of systems” section.

And then I uncovered two bigger systemic issues:

Two Systemic Problems You Might Also Have

Problem #1: Coders Couldn’t Find the Notes
In EPIC, our coders were reviewing notes using a particular workflow tab and the pre-anesthesia evaluations were buried and difficult to find.

This wasn’t just a one-off. Other hospitals in our online community confirmed this was an EPIC-based issue.

So if you’re a coding manager, make sure your coders know where to find these notes. Show them exactly how to access them and make it a priority.

Problem #2: The EMR was Working Against Us
Many vague terms (like “cardiac arrhythmia”) were pre-built in the EMR for quick-click selection. Manually typing/adding specific diagnoses (such as “persistent atrial fibrillation”) required a lot more clicks. Anesthesiologists simply were not going to do that and I don’t blame them.

We’re working on fixing that, but that represents bad EMR design and highlights the importance of including your CDI and coding department in any documentation-related EMR changes / builds.

So…Why Should Anesthesiologists Care?

Fair question.

I haven’t found any anesthesiology-specific risk-adjusted claims-based quality metrics. So I tried a few alternative motivators:

• Helping their surgical colleagues improve scores on metrics like Failure to Rescue (see my last newsletter).

• Reducing badgering from the UM department about the usage of that new, expensive reversal agent with improved hospital reimbursement.

Frequently Missed Comorbidities

Below is a list of frequently missed comorbidities in my audit

• Obesity

• Electrolyte derangements (hyponatremia, hypokalemia, metabolic acidosis)

• Chronic systolic and/or diastolic heart failure

• CKD (with stage) and ESRD

• Presence of pacemakers and the underlying arrhythmia

• Acute blood loss anemia and chronic anemias

• Previous stroke with residual effects

• Pulmonary Hypertension

• Underweight and/or cachexia

• Chronic respiratory failure with hypoxia

Final Thoughts

Anesthesiologists don’t need a complete overhaul of their documentation, just a bit of refinement (and visibility).

If you're a CDI/coding leader, take a look at:

• Where anesthesia notes live in your EMR and whether your coders are trained to capture their content

• How anesthesia templates and workflows are built (and how they can be optimized)

• And whether your anesthesia group understands their quiet but vital role in the hospital’s financial and quality metrics

And like David Glaser who ties in themed-songs on almost every episode of Monitor Mondays, Sarah McLachlan’s infamous song is playing in my mind’s ear. Anesthesia, I will remember you. Will you remember me?

Cheers,

Robert

Thanks to Laura Samson, RN BSN CCDS for editing this newsletter!

When you’re ready, there are 3 ways I can help you:

1. Join our CDI and Coding Village online community! It’s impossible to know it all, it takes a village! What you’ll get:

• Learn from me and other experienced professionals (perfect for new coders / CDI’s and those pivoting their career)

• Participate in monthly interactive webinars hosted by me, weekly 1 minute CDI quick tip videos, and anatomy and physiology reviews not found anywhere else

• Share ideas & solutions to new problems with peers in real-time discussions

2. Check out The Practical Guide to Attending Documentation video course.

• Stop underbilling your hard work & MASTER the new billing rules

• Get 3.5 hours of CME credit! (Use your CME funds!)

• Stop feeling guilty about writing shorter notes

• Use notes to PREVENT getting sued

3. Check out The Resident Guide to Clinical Documentation video course. The course that helps you:

• Impress your attendings and improve your evaluations.

• Prepare for real-world productivity pressures

• Gain the confidence to write shorter yet more effective notes.

• Use notes to make you a better, more prepared physician

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