When performing post-operative pain service, it is important to remember not only a complete procedure note is needed but also a written request from the surgeon. Surgeon’s must document, in writing, the need for anesthesia to assume management of post-operative pain. Keep in mind, a complete procedure note includes full detail of the service. See infographic below for a quick guide on Post-Op Pain Services.
Description of Infographic:
- Post-Operative pain services require a written request from the surgeon documenting the need for anesthesia’s expertise.
- The surgeon’s written request must be part of the patient’s medical record and producible for audit.
- Post-Operative pain services must be documented as a procedure note.
- Procedure note must include all elements:
- Intent
- Laterality
- Anatomical Location
- Preparation
- Description of Service
- Complications
- Rendering Provider
- Start/Stop Time
- Associated Post-operative pain service Procedure notes must be submitted to Ventra for billing.
