Seven Steps to Correct Surgical Coding
It’s all in how you dissect the operative report.
Many coders struggle with coding operative reports because there are so many guidelines and policies that affect code selection. The process is easier when you break it into seven steps:
- Review the header of the report.
- Review the CPT® codebook (start in the Index).
- Review the report/documentation.
- Make a preliminary code selection.
- Review the guidelines (for the preliminary codes).
- Review policies and eliminate the extras.
- Add any needed modifiers.
These seven steps will ensure all the factors that may affect code selection are accounted. Let’s look at an example, and walk through the steps together.
Step 1 Review the Header of the Report
What did the provider say was performed and why?
PREOPERATIVE DIAGNOSIS: Left medial compartment osteoarthritis of the knee.
POSTOPERATIVE DIAGNOSIS: Left medial compartment osteoarthritis of the knee.
PROCEDURE PERFORMED: Left unicompartmental knee replacement.
Based on the documentation above, an unicompartmental knee replacement on the left knee was performed. A unicompartmental knee replacement indicates only one of the three compartments of the knee (medial, lateral, or patellofemoral) was altered during the procedure. The postoperative diagnosis field indicates the altered compartment was the medial compartment of the left knee. Verification of the statement will take place as part of Step 3.
Step 2 Review the CPT® Codebook (Start in the Index)
What code options exist? What is required for each?
Based on the header information from the report, review the CPT® codebook to identify the code options. Also identify the differences between the codes and the documentation required to support one service over another.
Continuing with the example given, the Index is reviewed first to identify all possible code options for knee replacement procedures.
Intraoperative Use, Kinetic Balance
Sensor … +0396T
Partial … 27446
Total … 27447
Three options are given: +0396T Intra-operative use of kinetic balance sensor for implant stability during knee replacement arthroplasty (List separately in addition to code for primary procedure), 27446 Arthroplasty, knee, condyle and plateau; medial OR lateral compartment, and 27447 Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty).
Upon reviewing the three options, 0396T is found to be an add-on code, so it may not be reported alone, nor may it be the first-listed CPT® code reported. But it does indicate a specific technology was used during the procedure. If that technology is included in the full report (which will be reviewed in Step 3), +0396T will be included in Step 4 (Preliminary Code Selection).
CPT® codes 27446 and 27447 differ based on one key word: “OR” vs. “AND.” Code 27446 indicates a partial knee replacement (including either the medial OR the lateral compartment) was performed; whereas, 27447 indicates a total knee replacement (including both the medial AND lateral compartments) was performed. When the documentation is reviewed fully (Step 3), the primary focus will be to determine which compartments were altered during the procedure.
Step 3 Review the Report/Documentation Details
What does the documentation say?
Based on the documentation, a unicompartmental knee replacement using a Biomet, Inc., prosthesis was performed. The components were cemented into the tibia and distal femur after the necessary cuts and trial fit/placement were performed. According to the Cleveland Clinic, “Medial knee joint degeneration is the most common deformity of arthritis.”
Step 4 Make a Preliminary Code Selection
Which codes are supported by the documentation?
The emphasis here is to make a preliminary code selection based on the documentation. It’s preliminary because reviewing the guidelines, policies, etc., may lead to eliminating certain codes, or the need for additional codes and/or modifiers.
Based on the documentation above, a unicompartmental knee replacement is supported. A unicompartmental knee replacement is also referred to as a “partial” knee replacement, so based on the code options, CPT® code 27446 is supported, preliminarily. Guidelines, policies, and the like still need to be reviewed (Steps 5-7).
Note: If coding for a facility (as this procedure is fairly common in the outpatient facility or ambulatory surgery center setting), the implant also needs to be reported.
Step 5 Review the Guidelines
Are there other services to report separately? Is anything missing?
Review all relevant CPT® guidelines, including parenthetical references, to ensure all rules are followed, additional, supported services are captured, etc. Steps 5, 6, and 7 are all related, and are frequently performed concurrently.
The “Femur (Thigh Region) and Knee Joint/ Repair, Revision, or Reconstruction” CPT® codes do not include specific subsection guidelines. But there are two parenthetical references below code 27447 to review, and the general surgery guidelines (at the beginning of the Surgery section of CPT®) still apply.
The parenthetical references under 27447 read:
(For revision of total knee arthroplasty, use 27487)
(For removal of total knee prosthesis, use 27488)
Both parenthetical references are specific to total knee arthroplasties — particularly revision or removal of previously placed prosthesis — and are not relevant.
Based on the documentation for this scenario, a partial knee arthroplasty was performed in a knee without a previous prosthesis or implant. No additional CPT® guidelines appear to be relevant for this scenario.
Step 6 Review Policies and Eliminate the Extras
Are any of the services bundled?
Because there is only one service supported based on the documentation and steps above, it does not appear there are any extras. Review all of the relevant edits and policies (National Correct Coding Initiative (NCCI) edits, local and national coverage determinations (LCDs, NCDs), payer contracts, medical policies, etc.) to ensure bundled services are appropriately eliminated (and tracked internally, if applicable).
This step is essential in scenarios where more than one service is performed and more than one code may be warranted. Reviewing the NCCI edits and payer policies will help you identify bundled services, instances where modifiers may be needed, or situations where a contract limitation restricts reporting a service that would otherwise be reportable (e.g., a colonoscopy in which multiple procedures were performed such as snare polypectomy, biopsy polypectomy, and submucosal injection).
Step 7 Add Necessary Modifiers
Do the codes alone tell the full story of the service(s) provided?
Based on the description for 27446, there is no indication as to which knee was repaired. The story is incomplete. A modifier is needed to indicate which knee was affected.
Modifier options are:
LT eft side
RT ight side
50 ilateral procedure
Based on the documentation, the left knee was replaced because the patient had a right-side replacement previously. For this scenario, modifier LT is added to the procedure to indicate the procedure was performed on the left knee. Without this modifier, a denial or request for additional information may be received from the payer because the patient had the previous knee replacement.
Final code selection for this scenario is: 27446-LT.
Although the scenario used in this example is fairly straight-forward, these seven steps will work for any level of sophistication in an operative report. Use them for consistent review of all relevant factors, and correct coding is certain.
For more information on the Biomet device and procedure,