Coding for hospital outpatient surgery services can bring many challenges. For one thing, it's often a disjointed effort. Surgical or other clinical areas enter some charges, and coding staff then perform final coding and assignment of the surgical HCPCS/CPT codes to ensure accuracy.

Clinical staff usually use a Charge Description Master (CDM) to enter charges. CDMs contain descriptions for many outpatient surgery services such as certain ancillary services, supplies, drugs and biologicals, radiopharmaceuticals and sometimes certain surgical procedure codes.

In an ideal setting, clinical staff would enter most services via the chargemaster. From there, coders would assign the corresponding diagnosis codes and the surgical procedure codes. The coder may or may not see the codes that were assigned via the CDM. I recommend that coders have access to see all chargemaster-assigned codes so that they can review the accuracy. All procedure codes on the claim form should have an associated revenue code attached. A representative within a facility's billing department typically ensures that the correct revenue code is attached to the CPT or HCPCS code.

Careful not to get tripped up
Here are 5 areas you should review to avoid pitfalls in charging for CDM-driven codes.

Units of service for drugs. Review medical record documentation. Verify that the numbers of units charged for a particular drug are supported in the medical record documentation. If medication is wasted, be sure to include that information in the chart.

Bilateral procedures. Review payor policies to ensure the account is coded correctly. Some procedures are coded the same whether they're performed unilaterally or bilaterally. Ovarian biopsy is an example: 58900 (Biopsy of ovary, unilateral or bilateral [separate procedure]). Other procedures will require the use of modifier -50 and/or multiple units of service if performed bilaterally. The method of coding these varies by payor.

Procedures unlikely with the diagnosis code assigned. Review the full operative report and all other pertinent documentation (for example, the pathology report, progress notes, history and physical) for the encounter to ensure that the appropriate diagnosis codes have been reported. The surgical procedure performed should be compatible with the physician's documented diagnosis.

Unbundling of services. Some services and/or procedures are inherently a part of the operative procedure and should not be reported separately. For example, a patient presents for a diagnostic colonoscopy and a polyp is noted and removed via the snare technique. Because the diagnostic colonoscopy is a part of the greater snare removal, you'd select the code for colonoscopy with polypectomy.

Medical necessity. Both governmental and non-governmental payors expect that services provided will be medically reasonable and necessary. Ensure that coding and/or billing staff are familiar with medical necessity policies and are assigning only those diagnosis codes supported within the medical records documentation to address any accounts that are failing medical necessity.

Education key to clean claims
If your coding and billing staff knows the reasons for denials on the front end, it'll lead to fewer claims denials or rejections on the back end. Also be sure that everyone that participates in the entering and/or review of charges (the revenue cycle) both before and after claims submissions understands their role and how important it is to the entire process.