When I audit charts, it's not uncommon for me to find more than a few coding miscues, both omitted codes that resulted in underpayments and improper coding that resulted in overpayments. Here's a sampling of the errors that I found when I audited 2 months' worth of coding at a multi-specialty ambulatory surgical center. Use these 8 mini case studies to review your own charts. Chances are, you're either leaving money on the table, or collecting what's not yours.

Second breast excision missed

The Error The Medicare patient's case omitted code 19120-59-LT [excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant tissue, duct lesion, nipple or areolar lesion (except 19300), open, male or female, 1 or more lesions]. The patient had 2 lesions removed via separate incisions on the left breast. Per the OR Report, " ... incision was made at the lateral aspect of the left breast ... the mass was excised and removed ... same thing was done for the subareolar mass ... incision was made at the lateral aspect of the left areola ... mass was excised and removed."

The Fix Assign code 19120-LT for the second lesion as well.

Financial Impact No payment received for the second breast lesion excision, which would have been reimbursed at 50% of the payment group rate for code 19120.

Audit Tip Perform random reviews of accounts reported with 1 or more assignments of code 19120 to validate the number of separate incisions documented.

Wound debridement included the fascia

The Error The Medicare patient's case was inappropriately coded as 11042 [debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less]. Per the OR Report, fascia was debrided. "The wound was thoroughly debrided including skin, subcutaneous tissue, and fascia."

The Fix Delete code 11042 and replace it with code 11043 [debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less].

Financial Impact None. Both codes 11042 and 11043 are assigned to the same payment group, but this should not deter you from submitting a corrected claim to the payor.

Audit Tip Perform random reviews of accounts reported with wound debridement codes 11042 — 11047 to verify the depth of tissue debridement documented.

Over-coded colonoscopy

The Error The Medicare patient's colonoscopy with ascending colon and rectal biopsies was over-coded with codes 45380 and 45380-59.

The Fix Delete code 45380-59, since code 45380 classifies single or multiple biopsies: 45380 (colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple).

Financial Impact Inappropriate payment of code 45380-59 at 50% of the payment group rate.

Audit Tip Review all accounts in which code 45380 is reported more than once.

Rectal bleeding makes it a diagnostic colonoscopy

The Error The Medicare patient's pre-operative diagnosis was "rectal bleeding," but the colonoscopy was inappropriately coded as a screening exam with code G0121 (colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk). Since this patient had rectal bleeding as a chief complaint, for coding purposes this was a diagnostic colonoscopy.

The Fix Delete code G0121 and replace it with code 45378 [colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (separate procedure)].

Financial Impact Reduced payment inappropriately received because the payment rate for code G1021 is lower than the rate for code 45378.

Audit Tip Perform random reviews of accounts reported with colorectal screening codes G0121 or G0105 (colorectal cancer screening; colonoscopy on individual at high risk) to validate that the case was in fact a screening exam.

Limited vs. extensive shoulder arthroscopy

The Error The Medicare patient's case was inappropriately coded as 29822-LT (arthroscopy, shoulder, surgical; debridement, limited). Per the OR Report, several sites were debrided (they weren't repaired during this session). "There was degenerative tearing of the biceps at its insertion ... and debridement was performed. ... There were degenerative tears along the anterior and posterior aspect of the labrum, and debridement was performed with an arthroscopic shaver ... glenoid articular surface had degenerative changes ... and chondroplasty/debridement was performed.

The Fix Delete code 29822 and replace it with code 29823-LT (arthroscopy, shoulder, surgical; debridement, extensive).

Financial Impact Reduced payment inappropriately received because the payment rate for code 29822 is lower than the rate for code 29823.

Audit Tip Perform random reviews of accounts reported with code 29822 or 29823.

X-ray shows a tibial shaft fracture

The Error The Medicare patient's case was inappropriately coded as 27532-LT [closed treatment of tibial fracture, proximal (plateau); with or without manipulation, with skeletal traction]. Per the radiology report, the patient had a "tibial shaft fracture."

The Fix Delete code 27532-LT and replace it with code 27752-LT [closed treatment of tibial shaft fracture (with or without fibular fracture); with manipulation, with or without skeletal traction].

Financial Impact None. Both codes 27532 and 27752 are assigned to the same payment group, but this should not deter you from resubmitting a corrected claim to the payor.

Audit Tip Perform random reviews of fracture treatment codes to verify the location of the fractured bone.

Yes, but which bone was fractured?

The Error The Medicare patient's case was inappropriately coded as 26735-F1 (open treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb, includes internal fixation, when performed, each). Per the OR Report, the distal phalanx is the bone that was fractured and treated. "Open fracture, left index finger, distal phalanx. ... Open treatment, distal phalanx, left index finger."

The Fix Delete code 26735-F1 and replace it with code 26765-F1 (open treatment of distal phalangeal fracture, finger or thumb, includes internal fixation, when performed, each).

Financial Impact None. Both codes 26735 and 26765 are assigned to the same payment group, but this should not deter you from submitting a corrected claim to the payor.

Audit Tip Perform random reviews of fracture treatment codes to verify the location of the fractured bone.

Left money on the table with genital prolapse

The Error The Medicare patient's case was inappropriately coded as 57260 (combined anteroposterior colporrhaphy). Per the OR Report, an enterocele was also repaired "on the right side in the bladder, and the enterocele was bluntly dissected off the vaginal mucosa. ... In similar fashion, on the patient's left side, the same was performed, so that the cystocele as well as the enterocele could be reduced."

The Fix Delete code 57260 and replace it with code 57265 (combined anteroposterior colporrhaphy; with enterocele repair).

Financial Impact Reduced payment inappropriately received because the payment rate for code 57260 is lower than the rate for code 57265.

Audit Tip Perform random reviews of cases reported with code 57260 or 57265 to verify all conditions treated.