Data Entry Fields

Fields not appearing in this reference should be clearly labeled and collocated with the other elements of the section in question.

Patient Details

The information for fields appearing on the Patient Details tab is most often found in a table entitled “Patient Demographics” which, when present, appears in the Anesthesia Record and/or Billing System Details document.

• Patient Account# – The hospital account number assigned to the patient by the facility for financial recordkeeping. Most commonly appears alongside Guarantor information and often termed Guarantor Account.
• ENCN – Encounter Number. A numeric identifier assigned to the case by the facility. Sometimes called Visit ID. Unique for each case.
• MRN – Medical Record Number. A numeric identifier assigned to the patient by the facility. Sometimes called Patient ID. Unique for each patient. Should remain constant across all cases for a single patient.
  

Insurance Details

The information for fields appearing on the Insurance Details tab, when present, appears in the Anesthesia Record and/or Billing System Details document as above.

• Guarantor / Responsible Party – Info will appear in tables with Guarantor or Account in the name (Guarantor Information, Guarantor Account, Hospital Account, etc.). Insurance subscriber information should NOT be entered in this section. The individual identified should be clearly indicated as the guarantor or responsible party. If no such information is contained in the documents AND the patient is a legal adult (18 years of age or older), it is acceptable to assume that the patient is the guarantor (use the “Copy Patient Details” button to populate the section with the patient’s information).
• Insurance # – Info will appear in tables with Insurance or Coverage in the name (Coverage Information, Active Insurance, etc.). It is crucial to enter each insurance in the order in which it appears in the source documentation. This order determines the order in which each insurance will be billed. If the order is incorrect, a denial will occur.
• Approval NBR – Often labeled as prior authorization or precert #.
• Carrier Name/Code – The name of the insurance company, e.g. MEDICARE, BCBS, UHC, etc. Frequently identified as “Payor” in the source documentation. Populate with the same value as Plan Code if only the plan is identified.
• Plan Code – The free text name of an insurance plan.
• Policy NBR – May be labeled Member ID or Subscriber #/ID.
  

Other Details

• Case Time – Anesthesia Start and End Time info will appear in the “Events” table (Anesthesia Record), the “Procedure Summary” table (Anesthesia Record / Billing System Details), or the “Case Tracking Events” table (Anesthesia Record). Check Case Notes for corrections made by coders and/or reconcilers.
• Anesthesia End Time – When sourcing from an “Events” or “Case Tracking Events” table, use the latest time listed among those labeled “Handoff”, “Transfer to PACU”, or “Anes [Stop/End/Finish]”.
• Anesthesia Staff – Info for completing this area is found in the “Responsible Staff” or “Anesthesia Staff” table (Anesthesia Record / Billing System Details). Supporting information may be found in the “Procedure Summary” table (Anesthesia Record / Billing System Details). NOTE: additional “calculated” entries are sometimes included in this area to capture providers performing ancillary procedures like nerve blocks and ultrasounds. These entries should be left as is and can be identified by the contents of the “role” field, which will contain a comma delimited list of “[field]=[value]” pairs rather than a standard role description.
• Provider – Usually labeled “Name” in Responsible Staff table. Formatting is CRITICAL.
• Role – Enter the value from the “Role” column EXACTLY as it appears in the table. See note on calculated entries above.
• Start Time – If the preloaded value is earlier than the Anesthesia Start Time, revise to match.
• End Time – If the preloaded value is later than the Anesthesia End Time, revise to match.
• Responsible Provider – Set to “Yes” for the staff member appearing in the “Responsible Provider” field of the “Procedure Summary” table (Anesthesia Record / Billing System Data Entry). Should NEVER be set for “calculated entries” (see note under Anesthesia Staff).

Additional Details

• Surgeon – The medical care provider that the anesthesia staff is supporting, most commonly a surgeon. May also be an internist (GI cases) or OB/GYN (labor and delivery cases). Sometimes labeled as “Scheduled Providers”. Can be found in “Procedure Summary” (Anesthesia Record) or in the header of an Op Note document. Formatting is CRITICAL. Often recorded as PROVIDER in Case Notes.
• Patient Type – Type of anesthesia utilized in the case. Appears in multiple locations including “Procedure Summary”. Common values are “GA”, “general”, “TIVA”, “MAC”, “regional”, “spinal”, and “epidural”. Often incorrect in the source documentation. Check Case Notes first for corrected values.
• Admission Status – Records whether services were provided in an inpatient or outpatient setting. Commonly recorded in Case Notes.