Anaesthetic Billing Form
Anaesthetist
Hospital/Clinic
Surgeon
Patient Name
First Name
Last Name
Patient Information Sheet
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of
Date of case
 -
Day
 -
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Time In
Hour Minutes
AM
PM
AM/PM Option
Time Out
Hour Minutes
AM
PM
AM/PM Option
Tariff Rate
Standard Billing Rate
Standard Billing Rate PMB
Discovery Classic Rate
WCA
No co-payment
Procedure Name
ICD 10 Codes
Surgical Procedure Codes
Consultation:
Pre-op Consultation
Standard Anaesthetic Time
Emergency Consultation
Emergency Time
Hospital Follow-up Consultation
High Care Admission
ICU Admission
Ventilation First Day
Modifiers
Anaesthetic Assistant
One Lung Ventilation
ECMO
Hypothermia
Intra-aortic balloon pump
Positioning
Head, Neck, or Shoulder
Phaeo
Age
Neonate
Low birth weight
Blood Salvage
Blood Pressure Control
Yes
No
Start
Hour Minutes
AM
PM
AM/PM Option
Finish
Hour Minutes
AM
PM
AM/PM Option
BMI Check
Yes
No
Weight (kg)
Height (m)
Calculation
Anaesthetic Procedures
Arterial Line
Central Line
PCA
Spinal
Plexus Block
Epidural
Peripheral Nerve Block
Ultrasound-guided, hospital equipment
Naso-gastric tube
Bronchoscopy
TOE
CPR Check
Yes
No
Orthopaedic Modifiers
5441 Bones not in 5442-8
5442 Shoulder, scapula, clavicle, humerus, elbow joint, upper 1/3 tibia, knee joint, patella, mandible & TMJ
5443 Maxilla & Orbit
5444 Shaft of Femur
5445 Spine, Pelvis, Hip, NOF
5446 Sternum, Ribs
Notes
Signature
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