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Can you suggest an easy way to make sure our surgeons provide all the documentation we need in order to get paid and pass any audit that might occur?
A.
One idea is to prepare dictation forms for your surgeons. Arrange the form to remind the surgeon to include all the necessary details in the post-op reports. I developed the checklists below from a review of the current descriptions, guidelines, and notes for the American Medical Association's Current Procedural Terminology (CPT) surgery codes. You can do the same for the procedures in your surgical center.
- Photocopy and distribute the guidelines to the appropriate surgeons in your facility.
- Consider reducing the guidelines so that they can be carried in the surgeon's lab coat pocket.
- Consider designing forms that "capture" the documentation elements needed for optimal diagnosis and procedure code assignments.
- Share the guidelines with the surgeons in various forums: newsletters, meetings, and via your intranet.
HERNIA REPAIR (49495-49590, 49650-49659)
For reimbursement, you must state:
= Whether the patient has a past history of hernia repair surgery, and a brief description of the surgery, even if it occurred on the contralateral side.
= The patient's age.
= The type of unilateral or bilateral hernia(s) currently being repaired, i.e.:
- inguinal;
- sliding inguinal;
- lumbar;
- femoral;
- incisional (ventral);
- epigastric;
- umbilical;
- spigelian.
= The clinical presentation of each hernia(s), i.e. reducible, incarcerated or strangulated.
= The surgical repair method(s) used, i.e. open, laparoscopic, mesh application, etc.
SKIN GRAFTS (15050-15401)
For reimbursement, you must state:
= The type of skin graft (i.e., pinch, split-thickness, full-thickness, allograft, xenograft);
= The anatomical site for the donor skin graft;
= The surgical technique used to repair the donor site (e.g., simple suture, advancement flap, another skin graft);
= The size (in square centimeters) of the defect site (recipient) on which the graft is applied;
= The anatomical site (recipient) on which the graft is applied.
ARTHROSCOPIC KNEE MAJOR SYNOVECTOMY (29876)
or KNEE DEBRIDEMENT/CHONDROPLASTY (29877)
For reimbursement, you must state:
= Each compartment of the knee in which synovium is removed or cartilage is debrided:
- suprapatellar pouch;
- intercondylar pouch;
- medial compartment;
- lateral compartment.
FUNCTIONAL ENDOSCOPIC SINUS SURGERY
(31237 ????-???31294)
For reimbursement, you must state:
= The use of a nasal endoscope/telescope for each procedure performed;
= The type of ethmoidectomy performed unilaterally or bilaterally, i.e. partial (anterior only) or total (anterior and posterior);
= The type of maxillary antrostomy performed unilaterally or bilaterally, i.e. antrostomy alone or antrostomy with removal of tissue from the maxillary sinus, such as polyps or cysts;
= The performance of frontal sinus exploration unilaterally or bilaterally;
= The type of unilateral or bilateral sphenoidotomy performed, i.e. spheniodotomy alone or sphenoidotomy with removal of tissue such as polyps or cysts from the sphenoid sinus;
= The location of the cerebrospinal fluid leak repair, i.e. ethmoid or sphenoid region;
= The location of the surgical decompression, i.e. the medial orbital wall, the inferior orbital wall, or the optic nerve.
TURBINATE SURGERY
(30130, 30140, 30801, 30802, 30930)
For reimbursement, you must state:
= The disease process for each turbinate (e.g. hypertrophy).
= The type of procedure performed on each turbinate:
- excision;
- submucous resection;
- superficial cauterization/ablation;
- intramural cauterization/ablation;
- therapeutic fracture;
- reduction.
= Whether each procedure is unilateral or
bilateral.
= The surgical approach used for the turbinate surgery, i.e. open or endoscopic.
VITRECTOMY (66852, 67005-67040. 67108, 67112)
For reimbursement, you must state:
= The type of vitrectomy performed, either via an anterior approach or a posterior/pars plana approach.
= The method(s) used to perform the vitrectomy:
- non-mechanical (i.e., the use of Weck-cel sponges and scissors);
- mechanical (e.g., the use of vitrector, microvit, ocutome, retractor);
- injection of vitreous substitute;
- aspiration or release of vitreous;
- discission of vitreous strands;
- severing of vitreous strands.
HEMORRHOIDECTOMY (46083, 46221-46262, 46500, 46934- 46936, 46945, 46946)
For reimbursement, you must state:
= The type of hemorrhoid(s) present:
- tag;
- internal;
- external;
- internal and external;
- prolapsed;
- thrombotic.
= The location of each hemorrhoid plexus (i.e. there were internal hemorrhoids at 1, 2, 3, and 4 o'clock; there were four columns of internal hemorrhoids; there were internal hemorrhoids in all four quadrants).
= The surgical technique used to repair each hemorrhoid:
- incision;
- excision (hemorrhoidectomy);
- enucleation;
- injection of sclerosing agent;
- destruction (e.g., laser, electrocauterization);
- simple ligation (e.g., rubber band);
- ligation (surgical);
- fissurectomy;
- fistulectomy.
Lolita M. Jones, RHIA, CCS, is a Registered Health Information Administrator and a Certified Coding Specialist. She has more than ten years experience in publishing, training, and consulting for freestanding ASCs. If you have a coding question for Ms. Jones that you would like her to answer in this column, please e-mail it to [email protected] or send it to:
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