If your facility is like many I've seen that file claims without waiting for the final operative report, you may want to rethink this practice. As you'll see in these cases I've audited, your haste to prepare and submit your claims could easily result in lost revenue (due to held up, denied and underreported claims) or regulatory trouble (should you upcode and receive payments to which you're not entitled).

Blatant coding errors
The rush to code and bill these cases led to mistakes the staff easily would have averted had they waited for the final op report.

• Diagnostic vs. screening colonoscopy. The physician performed a video colonoscopy on a Medicare patient with a personal history of polyps and a family history of colon cancer. Without waiting for the physician's report, the coder billed it as a diagnostic colonoscopy (CPT 45378). The proper code is G0105 (colorectal cancer screening; colonoscopy on individual at high risk). The patient in the case clearly fit the high-risk designation and this was a screening, not a diagnostic, examination.
• Initial or subsequent paracentesis? Without the medical record, the coder could not possibly know whether to use the code for an initial paracentesis (49080) or subsequent paracentesis (49081).

Missed reimbursement opportunities
In this batch of cases, the final operative reports show that the facility billed for too little money because the surgeon performed more complex procedures than those indicated on the claim.

• Advancing a lesser claim. The facility removed a foreign body from the patient's GI tract. The operative report states, "... upper endoscope was then ... advanced ... The esophagus, stomach and proximal small intestine were seen ... Within the duodenal bulb, there was a piece of foreign body ... This was removed." Rather than coding the case with CPT 43247 (upper GI endoscopy with foreign body removal), the facility billed it as esophagoscopy with foreign body removal.
• Missing a layer of reimbursement. Although the coder properly noted the lesion removal, she did not bill for the wound closure. The facility was entitled to add CPT code 12051 (layer closure of extremity, 2.5cm or less) to the claim per the operative report notation that the "... lesion on the right wrist ... was completely excised ... The wound was closed in layers."
• Half the claim. The surgeon removed gynecomastia (CPT 19140) of both breasts, but the coder failed to note that the treatment was bilateral (19140 x 2). The patient's operative report didn't use the word "bilateral," but it did state that "the same procedure was done on the left side."

Botched multiple-procedure claims
Audits of these three cases turned up errors in which the facility missed the chance to collect deserved reimbursements for multiple procedures performed during the same operative session.

• A pair of benign errors. The surgeon excised two large warts on the patient's left index finger and, per the operative note, the warts "were fulgurated superficially by using CO2 laser." The coder inappropriately coded the case with CPT 11400 (excision of lesion, trunk, arms, legs), rather than a combination of 17000 (destruction, first benign lesion) and 17003 (destruction, second benign lesion).
• Omitted CPT codes. The facility did not assign any CPT codes to this multiple-lesion removal. The operative report indicated code 11442 (excision of benign lesion, ear, 1.1 to 2.0cm) for the following: "The one on the posterior portion of the ear near the helical edge was approximately 1.5cm ... The posterior lesion was excised first." Per the pathology report, this was a keloid (benign) lesion. The report also justified code 11440 (excision of benign lesion, ear, less than 0.5cm), stating, "The one on the lateral side was approximately 3mm ... The lesion on the lateral aspect was excised, and this was closed directly."
• Multiple mistakes in a single coding session. The patient had the following procedure inappropriately coded as a diagnostic laparoscopy (CPT 49320): "... operative scope was inserted ... left ovarian hemorrhagic cyst was drained." The proper code is 49322 (laparoscopy with drainage of cyst). Meanwhile, the following procedure was not coded at all: " ... operative scope was inserted ... left ovary was adherent to the posterior broad ligament ... left ovary was freed up entirely, and the sigmoid adhesions were released." Adding code 44200 (laparoscopy with lysis of intestinal adhesions) would have led to legitimate additional reimbursement. The operative report shows that the coder missed yet another reimbursable service, CPT 58662 (laparoscopy with fulguration of lesions). The report says, " ... operative scope was inserted ... endometrial implants were fulgurated." Finally, the coder could have added the following diagnosis codes: 614.6 (pelvic adhesions), 617.3 (endometriosis of ligaments) and 620.2 (ovarian hemorrhagic cyst).

Unsupportive documentation
These claims were not necessarily coded wrong, but nothing in the operative report substantiates them should the insurer balk.

• Under the microscope. The facility coded this diagnostic laryngoscopy case with CPT 31526 (laryngoscopy with operating microscope). But because the physician's report makes no mention of an operating microscope, it's not a clean claim as submitted. The more generic CPT 31525 (laryngoscopy diagnostic) is acceptable.
• Don't judge a report by its title. The facility coded this multiple procedure case as 31255 (endoscopic total ethmoidectomy), 31256 (endoscopic maxillary antrostomy) and 31276 (endoscopic frontal sinus surgery). Although the title of the operative report lists these procedures, the documentation in the body of the operative report only supports bilateral open total ethmoidectomies. The operative report doesn't mention the use of a scope, nor does it mention the antral meatoplasties of the frontal duct surgery. Cases such as this need to be re-reviewed with the physician - the documentation in the text must support the codes assigned and billed.
• Who removed the sutures? The facility billed for CPT code 15851 (removal of sutures under other than local anesthesia) for the "removal of sutures from groin." However, the physician's op report says nothing about the suture removal. Only a nurse documents this and there is no statement in her report that the physician was the one who removed the sutures. The best way to handle this case? Re-review it with the physician and delete CPT code 15851 if the physician did not remove the sutures under general anesthesia.

Upcoding
Upcoding - billing for a more expensive procedure than the one actually performed - may be unintentional but it can get you into trouble if you make a habit of it. Most commonly, upcoding errors arise from vague operative reports.

• An eye-opening omission. The coder assigned this patient's case CPT 67966 (more than one-fourth of eyelid margin excision and reconstruction). However, the physician didn't specify the extent of the eyelid defect, leaving the facility open to potential upcoding. The physician needs to officially amend the report to specify the percentage of the eyelid reconstruction. If he repaired less than one-fourth of the eyelid, the facility must delete code 67966 and assign 67961 instead.
• Be specific or be conservative. The operative report for this Medicare patient says that on the " ... upper eyelids ... a very conservative excision of the prolapsing fat was performed over a burnished eyelid plate." The coder assigned the case a CPT code corresponding to a bilateral external levator resection (CPT 67904 x 2). The case documentation doesn't reference the levator muscles at all. To avoid potential problems, the facility instead should use 15822 x 2 (bilateral upper eyelid blepharoplasties).
• Upcoding red flags. The facility severely overcoded this patient's hand surgery case. Nowhere does the documentation substantiate that the surgeon performed a finger volar plate repair (CPT 26548), a procedure performed so that the surgeon can access the operative field. The center should also delete HCPCS Level II implant code L8630, which classifies a metacarpophalangeal (MCP) joint implant. This item was not used in this case. To be consistent with the operative report, the surgeon would have placed screws (internal fixation devices), not joint implants.

Natural order of things
As you can see, coding without reviewing the final information can come back to haunt you. Simply taking the time to obtain and carefully review the final operative (and pathology) report, be it handwritten or dictated, will save you time, revenue and aggravation.