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Coding & Billing
5 Commonly Missed or Miscoded Procedures
Stephanie Ellis
Publish Date: October 10, 2007   |  Tags:   Financial Management

Stephanie Ellis, RN, CPC Could you be leaving money on the table without even knowing it? A quick way to find out is to test your knowledge of these five commonly missed or miscoded procedures. As you'll see, quite often the culprit is an op report that a physician didn't document well enough or a coder didn't read closely enough.

Stephanie Ellis, RN, CPC\ Claviculectomy performed with shoulder surgery.
The clavicle is joined at one end to the scapula or shoulder blade and at the other end to the sternum. The arthroscopic procedure for a partial distal claviculectomy (involving the removal of about 1cm of bone) is coded 29824. Code 23120 is for the open partial claviculectomy procedure and code 23125 is for the open total claviculectomy.

Keep in mind that a surgeon can perform an entire shoulder procedure arthroscopically. He may then perform a claviculectomy by a small incision, which you should code with the open code, rather than the arthroscopic code. Sometimes, the physician won't mention in the summary section of the op report that he performed a claviculectomy, making this a procedure that's easy to miss and code incorrectly.

Chondroplasty performed with knee arthroscopy.
Chondroplasty (or debridement) is frequently miscoded due to confusion over the Correct Coding Initiative, which unbundles edits for these codes. Rule No. 1: So long as you document that the chondroplasty procedure was performed in a separate compartment from the other procedure from which it is unbundled, you can bill for chondroplasty when you perform it with other arthroscopic knee procedures. This is so regardless of whether the 29877 code is unbundled in the CCI edits with an indicator of 0 or 1.

Billing Chondroplasty Procedures on Medicare Patients

  • Use the G0289 code in place of the 29877 code when billing chondroplasties performed in a separate compartment (when they are billable) to Medicare.
  • The ?59 modifier is not needed when billing the G0289 code.
  • Continue to use the 29877?59 code for payers other than Medicare.
  • For the G0289 code to be billable to Medicare, the physician is required to document in the op report that he spent at least 15 minutes performing the chondroplasty in the separate compartment from the other arthroscopic knee procedures he performed.
  • Also use G0289 for the removal of loose bodies or foreign bodies performed in a separate compartment from the other knee arthroscopy procedure from which the usual chondroplasty/loose body/foreign body codes are unbundled in the CCI unbundling material. The same documentation and billing requirements apply.
  • If a chondroplasty is the only procedure performed, use the 29877 code on Medicare claims.

The key is understanding which compartment the surgeon was in when he performed the chondroplasty and which compartment he was in (medial, lateral or patello-femoral, which includes the trochlear groove) when he performed the other knee arthroscopy procedure(s). Thorough review of these op reports is essential. Once you've clarified that the procedures were performed in different compartments, you're ready to code correctly for chondroplasty procedures. Keep these guidelines in mind:

  • If the chondroplasty is performed in the same compartment with the other arthroscopic surgery procedures, it would be considered bundled in most cases, and would not be separately billable. Check the CCI unbundling material to be sure.
  • The surgeon must document that he performed the chondroplasty in a different compartment than the repair or excision (in order to bill it with other procedures).
  • Use the ?59 modifier on the 29877 chondroplasty code to indicate it was performed in a separate area.
  • Chondroplasties can only be coded once per joint, regardless of how many compartments the surgeon debrides. So, for example, if the surgeon performs chondroplasty in more than one compartment, only use 29877 once.

Tendon grafts with ACL repair. When can you bill for obtaining a tendon graft used for arthroscopic ACL repairs? Only when you obtain it from the ankle area on the same leg or from the opposite knee. The 20924 code for a tendon graft states "from a distance." Billing 20924 code with the 29888 ACL repair code will likely be denied when you obtain the tendon graft from a separate incision on the same knee, because that's not considered to be a far enough distance to bill it separately, according to the CPT Assistant publication.

Stephanie Ellis, RN, CP\C Bladder tumors.
The physician's documentation in the op report must be extremely detailed to correctly code these procedures. Bill one code for each size/area of lesion that the surgeon removes. Bill the applicable code once for single or multiple tumors in the same size section. For example, if the surgeon fulgurates two small lesions, one medium tumor and three large tumors, you'd bill code 52234 x 1, code 52235 x 1 and code 52240 x 1. Don't add tumor sizes together to code these procedures; measure each tumor individually to determine the appropriate category from which to code. If the physician doesn't properly document tumor sizes in the op report, the pathology report won't be helpful, as the tumors are being fulgurated, not removed and sent for path.

Some other coding tips for bladder tumors:

  • When lesions are fulgurated (using laser or cryosurgery) in the areas of the trigone, bladder neck, prostatic fossa, urethra or periurethral glands, use code 52214.
  • For fulgurated bladder tumors classified as minor (less than 0.5cm), use code 52224.
  • For fulgurated bladder tumors classified as small (0.5cm to 2cm), use code 52234.
  • For fulgurated bladder tumors classified as medium (2cm to 5cm), use code 52235.
  • For fulgurated bladder tumors classified as large (more than 5cm), use code 52240.

Difficult cataracts.
Use the 66982 code to bill difficult cataract procedures for those patients with special problems that make the procedure more difficult, require the surgeon to use unusual techniques and involve a higher risk. Patients in this category include pediatric patients (under age 8) and patients with weakened or absent lens support structures from glaucoma, small pupils, subluxated lens, pseudoexfoliation, trauma, Marfan syndrome or uveitis.

You can only use 66982 for conditions the physician identified before the surgery. You can't use the code for difficulty with a normal cataract procedure or obstacles that arise (unexpectedly) during the normal cataract surgical procedure. For diagnosis coding of this procedure, list the cataract code first, then use the diagnosis code (glaucoma, for example) for the problem that made the surgery fall into the difficult category as the second diagnosis code. You must support the medical necessity for billing of this procedure.

3 Quick Cures for Your Coding Woes

Here are the three leading causes of careless coding and what you can do to prevent them.

  • Bad op reports. If the problem stems from a physician's poor op report documentation, address the issue with the physician directly, and have vigorous chart review follow-up to be sure documentation improves. Poor op reports not only jeopardize reimbursement, but they can also lead to fraud and abuse compliance issues with Medicare and other payers.
  • Coding from the schedule or superbill. If your coding and billing staff isn't fully reading op reports before billing the case, change your policies to require that they examine each op report in full before they bill. Coding from the schedule or some sort of a charge ticket or superbill document without reading the op report can cause compliance problems (billing procedures that might not have been fully documented) and diminish your bottom line (missing procedures that were performed, but weren't scheduled or recorded on the superbill document).
  • Coders not reading the entire op report. Another common mistake: coders only review the summary section at the beginning of the op report and don't read it. This is worrisome for a few reasons. Sometimes, procedures listed in the summary section weren't performed. Other times, procedures listed in the summary section were performed, but weren't documented in the body of the op report (unless another official document, such as a pathology report, can substantiate a procedure that wasn't documented in the body of the op report, you shouldn't bill them). And still at other times, procedures documented in the body of the op report aren't listed in the summary section at the beginning.

- Stephanie Ellis, RN, CPC

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