Coding is a complex process, growing even more involved as the healthcare industry gears up to switch to ICD-10. Ladonna Schaad, coding compliance manager at abeo, answers seven of the most common questions that arise around coding issues in ambulatory surgery centers.
Q: Why would a coder use different codes that those included in the physician's operative report?
Ladonna Schaad: Some of the codes are bundled together into combination code(s) that represent the procedures done. Or, perhaps, the one procedure is considered an integral part of the main procedure. A simple example would be that you would not code a laparotomy and an appendectomy individually. The laparotomy is considered a "separate procedure" and integral to the procedure as it is the approach to accomplish the appendectomy.
Coding suggestions from providers are definitely considered in giving the coder a "heads up" to look for the detail of the procedure(s) in the body of the operative report. It is the coder's responsibility to eliminate bundled codes and find the appropriate codes the provider is legally entitled to.
Q: Why would a coder not code a procedure mentioned just in the introduction of a physician's operative report?
LS: Coders look for the description of the procedure in the body of the operative report and do not assign codes based on the introduction or summary of the report. The rationale behind this is that the procedure may be intended but not completed or the template may be set up as a macro. The detail of the procedure in the body of the report will determine what code is assigned.
As we depend more and more on our electronic medical records, we have to be mindful that the physician should control the program, not the other way around. Macros are surely time savers, but not if they create misdirection or confusion in the reporting of procedures.
Q: Why would a coder assign a procedure an unlisted code?
LS: At times, there are no codes currently in place to use other than the unlisted code. For new technology it is especially difficult. While we may use an "almost-like-it" code to establish a price, we cannot assign that code. If we think back a number of years, there were no codes for arthroscopic procedures on the shoulders, for instance. The issuance of unlisted codes prompts the establishing of Category III codes for new procedures and the final CPT new codes eventually.
Q: Why would a coder use a different code than the one suggested by a vendor?
LS: Vendors want to be helpful to coders especially in new technology. But when you read the fine print, you will see that the provider is ultimately responsible for assigning a correct code. As a coder, we are ethically liable for determining the correct code and do a lot of research in authoritative sources to arrive at that code.
Notice I said authoritative sources. That does not mean taking the information available online from just any source. The best resources usually direct you to the back-up authoritative source to support their information. There is a wealth of information from what is considered recognized sources which would be CMS, AMA, CPT Assistant and AHA Coding Clinics. Coding organizations such as AHIMA and AAPC help to guide us to those sources as well. When all else fails, we will submit questions directly to the AMA, which may take some time in receiving the answer back, but we will have the information in writing at hand. Not everyone appreciates this thoroughness, but in this age of OIG and continuing audits, it helps support our coding choices.
Q: Why would a coder use a different code than one that has prior authorization?
LS:The documentation determines the code assigned by the coder. Often the physician may intend to perform a specific procedure and, during surgery, a slight change may occur that would prompt a different code. Usually a payer will respond favorably when the documentation is submitted explaining the change; my compliments to billing for following through so admirably on appeals.
Q: Should a coder use a different code after a claim is denied?
LS:Usually my first question would be, "Would you give me a little more information regarding the reason for the denial?" There are so many reasons that do not necessarily direct the question back to coding. Was the original authorization for a different code? Is the diagnosis code included in the Local Coverage Determination? Often, the provider may not give us the whole picture when submitting the diagnosis information. We recently had a procedure performed and the provider didn't mention in his documentation that the patient's condition included a history of cancer, which would have significantly impacted the medical necessity. With the addition of an addendum to the documentation to clarify the need for surgery, the charge was resubmitted.
Documentation is vital to support the medical necessity of any procedure. Occasionally the documentation may leave out important comorbid conditions or complications that may complicate or necessitate a procedure. Especially with the implementation of ICD-10, which will eventually happen, more detail is better.
Q: What happens if a physician disagrees with the code selection?
LS:There is an old saying in coding that you can put three coders in a room and they will each come up with slightly different codes. I would hope that it would not be the case, but I have seen it happen. Coders are not infallible and their interpretation of the documentation may differ from that intended by the physician. That does not mean that anyone is wrong, coding is not an exact science. Every physician dictates differently; no two charts or chart notes are exactly alike and even a few words in the detail may change the final coding.
The guidance of a physician is appreciated in helping to find the final code choice. Communication can certainly help both in understanding what is intended and whether additional documentation may be needed. There is the old adage “If it isn’t documented, it didn’t happen”. Coders are translators and are required to be extremely literal, translating verbiage into numbers to be submitted to insurance companies for reimbursement without embellishment or assuming procedures or diagnosis.
CPT copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
More Articles on Coding and Billing:
4 CMS Updates on ICD-10 to Know
5 Things to Know About Price Transparency in Healthcare & Surgery Centers
9 Threats to ASC Revenue Cycle Management Success
Q: Why would a coder use different codes that those included in the physician's operative report?
Ladonna Schaad: Some of the codes are bundled together into combination code(s) that represent the procedures done. Or, perhaps, the one procedure is considered an integral part of the main procedure. A simple example would be that you would not code a laparotomy and an appendectomy individually. The laparotomy is considered a "separate procedure" and integral to the procedure as it is the approach to accomplish the appendectomy.
Coding suggestions from providers are definitely considered in giving the coder a "heads up" to look for the detail of the procedure(s) in the body of the operative report. It is the coder's responsibility to eliminate bundled codes and find the appropriate codes the provider is legally entitled to.
Q: Why would a coder not code a procedure mentioned just in the introduction of a physician's operative report?
LS: Coders look for the description of the procedure in the body of the operative report and do not assign codes based on the introduction or summary of the report. The rationale behind this is that the procedure may be intended but not completed or the template may be set up as a macro. The detail of the procedure in the body of the report will determine what code is assigned.
As we depend more and more on our electronic medical records, we have to be mindful that the physician should control the program, not the other way around. Macros are surely time savers, but not if they create misdirection or confusion in the reporting of procedures.
Q: Why would a coder assign a procedure an unlisted code?
LS: At times, there are no codes currently in place to use other than the unlisted code. For new technology it is especially difficult. While we may use an "almost-like-it" code to establish a price, we cannot assign that code. If we think back a number of years, there were no codes for arthroscopic procedures on the shoulders, for instance. The issuance of unlisted codes prompts the establishing of Category III codes for new procedures and the final CPT new codes eventually.
Q: Why would a coder use a different code than the one suggested by a vendor?
LS: Vendors want to be helpful to coders especially in new technology. But when you read the fine print, you will see that the provider is ultimately responsible for assigning a correct code. As a coder, we are ethically liable for determining the correct code and do a lot of research in authoritative sources to arrive at that code.
Notice I said authoritative sources. That does not mean taking the information available online from just any source. The best resources usually direct you to the back-up authoritative source to support their information. There is a wealth of information from what is considered recognized sources which would be CMS, AMA, CPT Assistant and AHA Coding Clinics. Coding organizations such as AHIMA and AAPC help to guide us to those sources as well. When all else fails, we will submit questions directly to the AMA, which may take some time in receiving the answer back, but we will have the information in writing at hand. Not everyone appreciates this thoroughness, but in this age of OIG and continuing audits, it helps support our coding choices.
Q: Why would a coder use a different code than one that has prior authorization?
LS:The documentation determines the code assigned by the coder. Often the physician may intend to perform a specific procedure and, during surgery, a slight change may occur that would prompt a different code. Usually a payer will respond favorably when the documentation is submitted explaining the change; my compliments to billing for following through so admirably on appeals.
Q: Should a coder use a different code after a claim is denied?
LS:Usually my first question would be, "Would you give me a little more information regarding the reason for the denial?" There are so many reasons that do not necessarily direct the question back to coding. Was the original authorization for a different code? Is the diagnosis code included in the Local Coverage Determination? Often, the provider may not give us the whole picture when submitting the diagnosis information. We recently had a procedure performed and the provider didn't mention in his documentation that the patient's condition included a history of cancer, which would have significantly impacted the medical necessity. With the addition of an addendum to the documentation to clarify the need for surgery, the charge was resubmitted.
Documentation is vital to support the medical necessity of any procedure. Occasionally the documentation may leave out important comorbid conditions or complications that may complicate or necessitate a procedure. Especially with the implementation of ICD-10, which will eventually happen, more detail is better.
Q: What happens if a physician disagrees with the code selection?
LS:There is an old saying in coding that you can put three coders in a room and they will each come up with slightly different codes. I would hope that it would not be the case, but I have seen it happen. Coders are not infallible and their interpretation of the documentation may differ from that intended by the physician. That does not mean that anyone is wrong, coding is not an exact science. Every physician dictates differently; no two charts or chart notes are exactly alike and even a few words in the detail may change the final coding.
The guidance of a physician is appreciated in helping to find the final code choice. Communication can certainly help both in understanding what is intended and whether additional documentation may be needed. There is the old adage “If it isn’t documented, it didn’t happen”. Coders are translators and are required to be extremely literal, translating verbiage into numbers to be submitted to insurance companies for reimbursement without embellishment or assuming procedures or diagnosis.
CPT copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
More Articles on Coding and Billing:
4 CMS Updates on ICD-10 to Know
5 Things to Know About Price Transparency in Healthcare & Surgery Centers
9 Threats to ASC Revenue Cycle Management Success