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medically directed, supporting AA/QK/QX/QY/QZ modifier selection) Physical status assessment with supporting clinical rationale for P3 or higher classifications Pre-operative evaluation documenting informed consent and any comorbidities that affect physical status Post-anesthesia care unit (PACU) notes confirming patient recovery and discharge status Diagnosis codes matching the laterality and clinical presentation documented in the surgical record Practices that use consent and intake forms that flow into the clinical record reduce transcription errors between the pre-operative assessment and the billing record

Aftercare: You receive advice on possible effects, when to seek help and whether any follow-up is appropriate

Tkalcevi VI, Cuzi S, Brajsa K, Mildner B, Bokuli A, Situm K, Perovi D, Glojnari I, Parnham MJ