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Anaesthetic Billing Form

Record case details, procedure codes, timing, and vital-sign checks needed to bill anesthesia services accurately for a surgical case.

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Anaesthetist

Hospital/Clinic

Surgeon

Patient Name

Nombre

Apellido

Patient Information Sheet

Max 10 MB per file

Date of Case

Time In

Time Out

Tariff Rate

Rate 1 Rate 2 Rate 3 Emergency Rate

Procedure Name

ICD 10 Codes

Surgical Procedure Codes

Consultation

Initial Consultation Follow-up Consultation

Modifiers

Bilateral Procedure Multiple Procedures Reduced Services Increased Complexity

Blood Pressure Control

Within Normal Range Outside Normal Range

Start

Finish

BMI Check

Normal Overweight Obese

Weight (kg)

Height (m)

Anaesthetic Procedures

General Anesthesia Regional Anesthesia Local Anesthesia Sedation

CPR Check

Yes No

Orthopaedic Modifiers

Bilateral Procedure Assistant Surgeon Repeat Procedure

Notes

Signature

Sign here

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