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Lolita M. Jones, RHIA, CCS, a consultant specializing in ASC and hospital outpatient coding, billing, reimbursement and operations, discusses eight common ASC coding errors in seven different specialties.
General surgery
1. Excision of skin and soft tissue lesions. At the beginning of 2010, major coding changes were introduced regarding the excision of skin and soft issue lesions, adding a number of codes for the excision of soft tissue lesions to distinguish from the excision of skin lesions. "A number of coders are still coding for the skin system when it's actually from the musculoskeletal system," Ms Jones says. "Most payors will pay more for a soft tissue lesion excision than a skin lesion excision." She says centers may lose money if their coders have not properly analyzed yearly coding changes or lack the necessary knowledge on anatomy and physiology.
"In this case, it may be a matter of bulking up on their anatomy a little more and looking at some anatomical diagrams," she says. "They should be saying, 'I'm seeing that the lesion was removed all the way down to the subcutaneous tissue, and that takes me to musculoskeletal for coding.'"
Pain management
2. Spinal median branch blocks. According to Ms. Jones, the AMA published official guidelines around four years ago that said coders should not assign a code for the injection of each median branch when a physician is performing a median branch block. "Two median branches in the spine actually support one facet joint, so if two median branches are blocked with an anesthetic, the official guideline is to code that as a single facet joint injection," she says.
She says in her experience, coders often report an injection code for each median branch. "That's over-coding (up-coding), and the AMA recently reiterated its guideline," she says. "Unfortunately, not only are the coders doing that, but physicians who do their own coding in the ASC are doing it as well. They'll say, 'I placed two needles in two different locations,' but the AMA understands that and [still insists that one facet joint injection code is appropriate]."
She says coders who submit codes for two injections will be overpaid, and payors will likely not notice the error unless the payor requests the operative report. She says centers can run into trouble if their coding processes are audited and mistakes like this are discovered. "Even if they say, 'We didn't know about the guidelines', OIG doesn't care about that," she says.
Orthopedic surgery
3. Arthroscopic shoulder surgery. According to Ms. Jones, when patients come in for arthroscopic shoulder surgery, coders will often assign a code for arthroscopic distal claviculectomy when, in fact, the physician may have simply removed osteophytes or spurs from the clavicle. "The removal of spurs from the clavicle should be coded as acromioplasty, and that's another area where the payor wouldn't know what's wrong and the ASC would walk away with too much money," she says.
She says even experienced coders may be tripped up by mistakes like this, simply because cases are shifting from the hospital setting to the ASC setting. "Years ago, you would only see these procedures in a hospital inpatient unit," she says. "Coders really need to bone up on anatomy and physiology and, [if they can], the ASC should invest in anatomy and physiology software."
4. Hammertoe repairs. Another common problem with orthopedic coding occurs with hammertoe repairs, Ms. Jones says. She says hammertoe repair CPT codes can be used for any technique used to repair a hammertoe, whether the procedure is done using a fusion technique or a hemiphalangectomy. "Some coders get hung up on technique and literally go and assign a code for fusion or for hemiphalangectomy, when there's actually a code that exists for hammertoe repair," she says.
In either case — whether the coder is mistakenly coding for fusion or hemiphalangectomy instead of hammertoe repair — Ms. Jones says this error will lose the ASC money.
ENT
5. Nasal sinus surgery. "I find a number of issues with nasal sinus surgery, and the big issue would have to be the coding of the removal of tissues on the maxillary sinus," Ms. Jones says. She says there are two categories of codes that give the coder the option of reporting sinus surgery with the removal of tissue and without, and frequently coders will assign a code that does not involve tissue removal when the procedure involved tissue removal from the maxillary sinus. She says this may not be an issue of under- or over-payment, but rather an issue of coding compliance.
She says coders may fall down on sinus surgery codes because the frequency of the surgeries has picked up in recent years. "People are living longer, and years ago, sinus wasn't a big deal and there wasn't a lot of surgery," she says. "Now people are coming in with all sorts of sinus troubles, and coders are seeing procedures they probably never saw in the past."
OB/GYN
6. Cystocele or rectocele repair. According to Ms. Jones, codes differ for cystocele and rectocele repair based on how the physician performs the surgery. "These are complex operative reports to deal with, and there are so many codes to choose from based on the approach, the defect being repaired and the combination of defects," she says. "These are high-dollar procedures, so when you make a mistake there, it's not good."
She says this common mistake necessitates research by the coders, as well as careful reading of every operative report.
Ophthalmology
7. Complex cataract repair. CPT 66982 is assigned to complex cataract repair. According to Ms. Jones, guidelines start that multiple sphincterotomies during a cataract extraction justify coding the procedure as a complex cataract repair. "A lot of coders are not aware of all the elements that would justify a complex cataract repair, and I'm starting to see that more and more [with] multiple sphincterotomies," she says. She adds that failing to code as a complex cataract repair will have an adverse impact on ASC payment.
GI/Endoscopy
8. Endoscopic injection of polyps. Ms. Jones says she still finds a number of coders failing to report the endoscopic injection of polyps during GI/endoscopy surgeries. "There are special codes for what is called 'submucosal injection' of a GI lesion, which occurs when a physician injections a polyp with saline or ink," she says. "Whenever something like ink or saline is injection, [the procedure] should be coded as a submucosal injection, and I'm still finding there's a 50/50 chance it won't be coded." She says the coder will often notice the removal of the polyp but miss the injections — or believe the injection was incidental in the polyp's removal.
The information provided should be utilized for educational purposes only. Please consult with your billing and coding expert. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.
Lolita M. Jones, RHIA, CCS, a consultant specializing in ASC and hospital outpatient coding, billing, reimbursement and operations, discusses eight common ASC coding errors in seven different specialties.
General surgery
1. Excision of skin and soft tissue lesions. At the beginning of 2010, major coding changes were introduced regarding the excision of skin and soft issue lesions, adding a number of codes for the excision of soft tissue lesions to distinguish from the excision of skin lesions. "A number of coders are still coding for the skin system when it's actually from the musculoskeletal system," Ms Jones says. "Most payors will pay more for a soft tissue lesion excision than a skin lesion excision." She says centers may lose money if their coders have not properly analyzed yearly coding changes or lack the necessary knowledge on anatomy and physiology.
"In this case, it may be a matter of bulking up on their anatomy a little more and looking at some anatomical diagrams," she says. "They should be saying, 'I'm seeing that the lesion was removed all the way down to the subcutaneous tissue, and that takes me to musculoskeletal for coding.'"
Pain management
2. Spinal median branch blocks. According to Ms. Jones, the AMA published official guidelines around four years ago that said coders should not assign a code for the injection of each median branch when a physician is performing a median branch block. "Two median branches in the spine actually support one facet joint, so if two median branches are blocked with an anesthetic, the official guideline is to code that as a single facet joint injection," she says.
She says in her experience, coders often report an injection code for each median branch. "That's over-coding (up-coding), and the AMA recently reiterated its guideline," she says. "Unfortunately, not only are the coders doing that, but physicians who do their own coding in the ASC are doing it as well. They'll say, 'I placed two needles in two different locations,' but the AMA understands that and [still insists that one facet joint injection code is appropriate]."
She says coders who submit codes for two injections will be overpaid, and payors will likely not notice the error unless the payor requests the operative report. She says centers can run into trouble if their coding processes are audited and mistakes like this are discovered. "Even if they say, 'We didn't know about the guidelines', OIG doesn't care about that," she says.
Orthopedic surgery
3. Arthroscopic shoulder surgery. According to Ms. Jones, when patients come in for arthroscopic shoulder surgery, coders will often assign a code for arthroscopic distal claviculectomy when, in fact, the physician may have simply removed osteophytes or spurs from the clavicle. "The removal of spurs from the clavicle should be coded as acromioplasty, and that's another area where the payor wouldn't know what's wrong and the ASC would walk away with too much money," she says.
She says even experienced coders may be tripped up by mistakes like this, simply because cases are shifting from the hospital setting to the ASC setting. "Years ago, you would only see these procedures in a hospital inpatient unit," she says. "Coders really need to bone up on anatomy and physiology and, [if they can], the ASC should invest in anatomy and physiology software."
4. Hammertoe repairs. Another common problem with orthopedic coding occurs with hammertoe repairs, Ms. Jones says. She says hammertoe repair CPT codes can be used for any technique used to repair a hammertoe, whether the procedure is done using a fusion technique or a hemiphalangectomy. "Some coders get hung up on technique and literally go and assign a code for fusion or for hemiphalangectomy, when there's actually a code that exists for hammertoe repair," she says.
In either case — whether the coder is mistakenly coding for fusion or hemiphalangectomy instead of hammertoe repair — Ms. Jones says this error will lose the ASC money.
ENT
5. Nasal sinus surgery. "I find a number of issues with nasal sinus surgery, and the big issue would have to be the coding of the removal of tissues on the maxillary sinus," Ms. Jones says. She says there are two categories of codes that give the coder the option of reporting sinus surgery with the removal of tissue and without, and frequently coders will assign a code that does not involve tissue removal when the procedure involved tissue removal from the maxillary sinus. She says this may not be an issue of under- or over-payment, but rather an issue of coding compliance.
She says coders may fall down on sinus surgery codes because the frequency of the surgeries has picked up in recent years. "People are living longer, and years ago, sinus wasn't a big deal and there wasn't a lot of surgery," she says. "Now people are coming in with all sorts of sinus troubles, and coders are seeing procedures they probably never saw in the past."
OB/GYN
6. Cystocele or rectocele repair. According to Ms. Jones, codes differ for cystocele and rectocele repair based on how the physician performs the surgery. "These are complex operative reports to deal with, and there are so many codes to choose from based on the approach, the defect being repaired and the combination of defects," she says. "These are high-dollar procedures, so when you make a mistake there, it's not good."
She says this common mistake necessitates research by the coders, as well as careful reading of every operative report.
Ophthalmology
7. Complex cataract repair. CPT 66982 is assigned to complex cataract repair. According to Ms. Jones, guidelines start that multiple sphincterotomies during a cataract extraction justify coding the procedure as a complex cataract repair. "A lot of coders are not aware of all the elements that would justify a complex cataract repair, and I'm starting to see that more and more [with] multiple sphincterotomies," she says. She adds that failing to code as a complex cataract repair will have an adverse impact on ASC payment.
GI/Endoscopy
8. Endoscopic injection of polyps. Ms. Jones says she still finds a number of coders failing to report the endoscopic injection of polyps during GI/endoscopy surgeries. "There are special codes for what is called 'submucosal injection' of a GI lesion, which occurs when a physician injections a polyp with saline or ink," she says. "Whenever something like ink or saline is injection, [the procedure] should be coded as a submucosal injection, and I'm still finding there's a 50/50 chance it won't be coded." She says the coder will often notice the removal of the polyp but miss the injections — or believe the injection was incidental in the polyp's removal.
The information provided should be utilized for educational purposes only. Please consult with your billing and coding expert. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.