Coding & Billing


Improper Coding's Impact on Your Bottom Line

I recently completed an extensive audit of three ASCs, each affiliated with a major hospital corporation. While the physician documentation in the 250-plus operative reports we reviewed was fairly comprehensive, we uncovered several coding errors across all specialties that would have lead to both overpayments and underpayments.

1. Excision of lesion with advancement flap closure
Delete the excision of malignant lesion code 11603 and the complex wound repair code 13132. Assign code 14041 (Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10.1 sq cm to 30.0 sq cm). Per the operative report, "I proceeded full-thickness excision of the lesion... wound measured 6 cm in length x 2cm in vertical height. I undermined the adjacent tissue circumferentially for 1 x 1.5 cm. I then advanced the lower skin flap cephalad ..." This text documents the excision of a lesion with adjacent tissue transfer/advancement flap closure of the defect site. "If a lesion is excised and an adjacent tissue transfer or rearrangement is performed at the same site, excision of the lesion is not reported separately," per the American Medical Association's (AMA) CPT Assistant newsletter, July 1999.

InCorrect. 11603 (APC 020, $121.28 x 50%) +13132 (APC 135, $115.28 at 100%) = 175.92
Correct. 14041 (APC 136, $538.23 at 100%) = $538.23

2. Arthroscopic Mumford and post-op pain nerve block
Delete code 29827 [Arthroscopy, shoulder, surgical; with rotator cuff repair], since there's no documentation for this procedure. Assign code 29824-LT [Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford procedure)] to classify the "Arthroscopic complete Mumford procedure" per the operative report. Also add code 64418-59 (Injection, anesthetic agent; suprascapular nerve) to classify the "suprascapular nerve block" performed for post-operative pain control per the operative report (Source: October 2001 CPT Assistant newsletter, AMA).

InCorrect. 29827 (APC 042, $1,010.83 at 100%) = $1,010.83
Correct. 29824 (APC 041, $835.63 at 100%) + 64418 (APC 206, $76.99 x 50%) = $874.12

3. Metatarsal exostectomies
Delete code 25931 (Transmetacarpal amputation; re-amputation), and assign codes 28122-RT and 28122-59-RT 28122 [Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, osteomyelitis or bossing); tarsal or metatarsal bone, except talus or calcaneus]. Code 25931 classifies hand surgery performed on the metacarpals; this case involved foot surgery performed on the metatarsals. Per the operative report, "Distal portion of the second metatarsal was identified and bony exostosis ... was resected ... third metatarsal ... bony exostosis was again noted ... was removed ..."

InCorrect. 25931 (APC 049, $880.55 at 100%) = $880.55
Correct. 28122 (APC 055, $598.08 at 100%) + 28122 (APC 055, $598.08 x 50%) + 28122 (APC 055, $598.08 x 50%) = $1,196.16

4. Bronchosopy with Brushing and BAL
Code 31628 is Correct. Add codes 31623-RT [Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; with brushing or protected brushings] and 31624-RT [Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; with bronchial alveolar lavage]. Per the OR Report, "There was a fish-like slit opening of the bronchus intermedius. This was brushed twice ... a BAL was subsequently performed at the right upper lobe." Per the AMA's May 2008 CPT Assistant newsletter, "It is appropriate to report multiple procedures performed during a single bronchoscopy."

InCorrect. 31628 (APC 076, $437.56 at 100%) = $437.56
Correct. 31628 (APC 076, $437.56 at 100%) + 31623 (APC 076, $437.56 x 50%) + 31624 (APC 076, $437.56 x 50%) = $875.12

5. Full-thickness skin graft
Delete codes 15002 (Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar) and 15100 [Split-thickness autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children (except 15050)], and assign code 15220 [Full thickness graft, free, including direct closure of donor site, scalp, arms, and/or legs; 20 sq cm or less]. Per the OR Report, the graft was full-thickness, not split-thickness. "A full-thickness skin graft was then harvested from the left thigh ...," it says.

InCorrect. 15100 (APC 137, $543.65 at 100%) + 15002 (APC 135, $289.31 X 50%) = $688.30
Correct. 15100 (APC 137, $543.65 at 100%) + 15220 (APC 136, $490.23 x 50%) = $788.76

6. Tympanoplasty for tympanic membrane perforation
Delete code 69610-LT [Tympanic membrane repair, with or without site preparation of perforation for closure, with or without patch], and assign code 69631-LT [Tympanoplasty without mastoidectomy (including canalplasty, atticotomy and/or middle ear surgery), initial or revision; without ossicular chain reconstruction]. "Code 69610 is intended to describe the procedure in which the physician freshens the edges of the perforated area of the tympanic membrane, after which the physician may or may not apply a paper patch to the site as indicated." (Source: March 2001 CPT Assistant newsletter, AMA). Per the operative report, the physician did more than freshen the edges of the perforation: "Left underlay tympanoplasty ... A tympanomeatal flap was then elevated ... temporalis full fascia graft was harvested ... laid into the middle ear space ... perforation had excellent coverage ..."

InCorrect. 69610 (APC 254, $178.18 at 100%) = $178.18
Correct. 69631 (APC 256, $950.49 at 100%) = $950.49

7. Tissue expander replacement with breast implants
Delete codes 19330-50 (Removal of mammary implant material) and 19325-50 (Mammaplasty, augmentation; with prosthetic implant). Assign code 11970-50 (Replacement of tissue expander with permanent prosthesis - bilateral). Per the OR Report, "Bilateral removal of saline expanders and placement of permanent silicone prosthesis" was performed. In addition, there is no documentation in the OR Report that that tissue expander was not intact, so the "removal of implant material" code 19330 is not appropriate.

InCorrect. 19330-50 (APC 029, $577.99 x 150%) = $866.98
Correct. 11970-50 (APC 051, $827.41 at 150%) = $1,241.11

8. Decompression fasciotomy with debridement
Delete codes 11042 (Debridement; skin, and subcutaneous tissue), 27602-LT [Decompression fasciotomy, leg; anterior and/or lateral, and posterior compartment(s)], and 27892-LT [Decompression fasciotomy, leg; anterior and/or lateral compartments only, with debridement of nonviable muscle and/or nerve]. Assign code 27894-50 [Decompression fasciotomy, leg; anterior and/or lateral, and posterior compartment(s), with debridement of nonviable muscle and/or nerve]. Per the operative report, "... left leg ... posterior and lateral compartments... fasciotomy was done ... necrotic muscle ... was excised ... extensive debridement was done ... right leg ... excisional debridement ... all the necrotic tissue ... and necrotic muscle ... Fasciotomy was done... deep posterior compartments, lateral compartments as well as anterior compartment."

InCorrect. 27602 (APC 049, $602.64 at 100%) + 27892 (APC 049, $602.64 x 50%) + 11042 (APC 016, $150.85 x 50%) = $979.38
Correct. APC 27894-50 (APC 049, $602.64 x 150%) = $903.96

9. Bilateral orchidopexy
Append bilateral procedure modifier -50 to code 54600 (Reduction of torsion of testis, surgical, with or without fixation of contralateral testis). Per the OR Report, "Bilateral scrotal orchidopexy" was performed.

InCorrect. 54600 (APC 183, $703.57 at 100%) = $703.57
Correct. 54600-50 (APC 183, $703.57 x 150%) = $1,055.35

10. Hammertoe repair via interphalangeal fusion
Delete code 26860-RT (Arthrodesis, interphalangeal joint, with or without internal fixation) and assign code 28285-T5 [Correction, hammertoe (eg, interphalangeal fusion, partial or total phalangectomy)]. Code 26860 classifies the finger interphalangeal joint. Per the operative report, "Deformed hammertoe ... Hallux valgus interphalangeal joint fusion of the right great toe." Code 28285 classifies hammertoe repair, including the interphalangeal fusion technique for the repair.

InCorrect. 26860 (APC 054, $654.82 at 100%) =
Correct. 28285 (APC 055, $598.08 at 100%) =

11. AlloDerm application
Code 57300 (Closure of rectovaginal fistula) is Correct. Delete code 57267 [Insertion of mesh or other prosthesis for repair of pelvic floor defect, each site (anterior, posterior compartment), vaginal approach (List separately in addition to code for primary procedure)]. Per the parenthetical note underneath code 57267 in the CPT code book "(Use 57267 in addition to 45560, 57240 ??" 57265)." Add-on code 57267 cannot be reported with code 57300. Please assign code 15335 [Acellular dermal allograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less]. Per the operative report, "Repair of rectovaginal fistula with AlloDerm and rectal advancement flap."

InCorrect. 57267 (APC 195, $1,081.84 at 100%) + 57300 (APC 195, $718.09 x 50%) = $1,440.88
Correct. 57300 (APC 195, $718.09 at 100%) + 15335 (APC 135, $289.31 x 50%) = $862.74

12. Extraocular scarring during strabismus surgery
Code 67314 (Strabismus surgery, recession or resection procedure; one vertical muscle) is Correct. Add code 67332-RT [Strabismus surgery on patient with scarring of extraocular muscles (eg, prior ocular injury, strabismus or retinal detachment surgery) or restrictive myopathy (eg, dysthyroid ophthalmopathy) (List separately in addition to code for primary procedure)]. Per the operative report, "There was extensive scarring and restrictions secondary to the Graves disease."

InCorrect. 67314 (APC 243, $722.24 at 100%) = $722.24
Correct. 67314 (APC 243, $722.24 at 100%) + 67332 (APC 243, $722.24 x 50%) = $1,083.36

13. Loop Electrode Excision Procedure (LEEP)
Delete code 57460 [Colposcopy of the cervix including upper/adjacent vagina; with loop electrode biopsy(s) of the cervix]. There is no OR Report documentation of a colposcopy being performed. Assign code 57522 (Conization of cervix, with or without fulguration, with or without dilation and curettage, with or without repair; loop electrode excision).

InCorrect. 57460 (APC 193, $172.39 at 100%) = $172.39
Correct. 57522 (APC 193, $531.37 at 100%) = $531.37

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