Sean McSweeney, founder and president of Apache Health, a Los-Angeles based medical billing company, gave four insightful tips on documentation for accurate coding:
1. Detailed reporting of procedures performed in an itemized fashion, as well as a description of the itemized procedures in the body of the report, is a must.
2. Detailed reporting would include the sizes and lengths of a mass or lesion, and detailing excision versus debridement.
3. Document complexity by writing a paragraph solely dedicated to explaining the complexity of the procedure to increase procedural services (modifier 22).
4. The medical necessity for a co-surgeon or an assistant (AS, 80, 62) is becoming more important in today’s climate.