Ask an Auditor: FAQs Auditing Operative Reports

Lori: Hello everyone, and welcome to our "AAPC Services Podcast." My name is Lori Cox and I will be the host today. We're gonna chat about auditing operative reports. I have two wonderful guests with me today. I'd first like to introduce Elizabeth Hylton. Elizabeth, welcome. Can you tell us a little bit about yourself?

Elizabeth: Absolutely. Thanks so much for having me today. I got my start looking over coding denials. And I have pretty much functioned in every capacity there is to function in a medical office specifically. I've done denials work, I've worked front desk, precertification, any type of coding-related stuff that you can think of, I've done it. I've also had the opportunity to manage a practice. So, from a revenue cycle perspective, I've got a little bit of experience. And I've spent the last six or so years in the audit world looking over documentation, making sure that all the elements that we need is in there. So, jack of all trades.

Lori: Yes, absolutely. That's what you almost have to be in this world today. And my second guest today is Viola Apostoli. Welcome, Viola. Would you like to give us a little bit of background?

Viola: Well, thank you for having me. It's really an honor. And yes, so like Elizabeth, a little bit of a jack of all trades as well. I started with charge entry in 2008. And from there, I learned pretty much all denial, auditing, coding, billing. And then for the last six and a half, seven years, I've also been doing auditing education, just to make sure we have all the elements as well.

Lori: Perfect. Thank you both for being here today. We'll just jump right in here and get started. So Elizabeth, the first question I have for you is do you have a document that states what must be included in an op report? Is there a comprehensive list with specific elements?

Elizabeth: I tend to try and utilize all resources that I can at my disposal, so I wouldn't say I've narrowed it down to one specific place. I like to pull in sources that corroborate one another. But at the very least, the op report should include a preoperative and postoperative diagnosis, the reason for the procedure, a description of the procedure, any type of complications that occurred, and the condition of the patient after surgery. That's kind of like a general bullet point that you want to see. If you want a specific place to look, I would recommend the JCAHO website, that's www.jointcommission.org.

Lori: Very good. Thank you. Okay, Viola, your turn. Should there be an indication of why the procedure was performed?

Viola: Absolutely, that should always be on any procedural note that is performed. That is your basis in establishing medical necessity. That is telling your payer, CMS, and anybody reviewing that note why are you doing this procedure? And was it truly medically necessary?

Lori: Right. We always know medical necessity is one of the most important things in our world, that's for sure. Elizabeth, what if license...sorry, license...lysis of adhesions takes an additional five hours, above and beyond the time associated with the main procedure being performed, would you still only use Modifier 22 to capture this revenue?

Elizabeth: Well, first off, bless that poor surgeon's heart. But ultimately, we're gonna need to check CCI edits for the code for the main procedure and see if lysis of adhesions is gonna be bundled with that. If that is the case and they are bundled, you can only use Modifier 22 to account for the extra work associated with the lysis. You're not typically going to report those separately unless there is a different site involved.

Lori: Exactly. All right, Viola, what area do you code from in the op note, the pre-op, post-op findings, descriptions? Where do you get your diagnosis codes from?

Viola: I normally go to the procedure note itself. This is where you will see what was found, what was discovered, what truly was done. The pre-op diagnosis is really just to necessitate the procedure, and the post-op diagnosis doesn't always give you the full diagnosis with the most specificity, whereas your op note itself will have all that description that you could find the most detailed in the diagnosis with the greatest specificity.

Lori: Right. Exactly. Elizabeth, is there a specific timeframe for signing up notes that payers have outlined?

Elizabeth: I have not found anything in black and white that outlines this is an absolute. However, my experience, the typical standard is going to be what is recommended by CMS, which is the 72-hour rule. Make sure everything is signed off and finalized within three days because again, we're looking to make sure that the integrity of the note is maintained. We don't want a signature that is late and has the possibility of challenging what is in the operative report itself. Because of course, if we're called upon to defend this in a court of law, then the information in the note needs to be reliable. And one of the places that we look to make sure that that is the case is how long it took the surgeon to authenticate it and finalize it.

Lori: Right. I know I don't usually remember what I had for breakfast, I can't imagine being able to reiterate an op note, you know, like five or six days later. That's impossible to do. I hope sometime soon in the future that we get a rule either by CMS or, you know, one of the payers, they just finally lay down a law and say this is what it has to be. That would help a lot of us, I do believe.

Elizabeth: Yes, ma'am.

Lori: All right. Viola, we have a lot of questions that came in about assistants at surgery, so I'm gonna start with the first one. Can an assistant at surgery or a surgical assistant report for all procedures that they render or assist with?

Viola: That is such a good question. And the answer to that is no, not always. Medicare has a payment policy that has indicators as we all know. And the indicators of zero and one are the ones that we need to pay close attention to determining whether a procedure performed by an assistant at surgery or a surgical assistant can be reported. A payment indicator of one is a statutory payment that has a restriction for assistants at surgery. Payment indicator of zero also has a restriction, but sometimes for different circumstances, they can be reported based on supporting documentation, and they may be submitted. But anything with an indicator of one, it cannot be reported.

Lori: And they can find those indicators on the CMS website, right?

Viola: Yes. The Physician Fee Schedule Lookup Tool is a very handy schedule and that is located at www.cms.com. It is a really user-friendly tool as well.

Lori: Yeah, I agree. And I think most especially newer coders coming in, I don't think they realize there's more to that fee schedule than just the dollar amounts. That there's a whole bunch of different kinds of indicators and things on there. So that was a good point. Thank you. Elizabeth, when coding for a skin excision, can you use the sizes off of the path report if none are documented in the op note?

Elizabeth: That would absolutely be a last resort that I would recommend, because the skin is very stretchy, and once you cut out the lesion it will shrink once it's removed. The dimensions on the path report will be smaller than if the surgeon would measure beforehand and include margins, etc. So, it can be done, but we recommend measure it first because you're gonna shortchange yourself some revenue if you end up coding from the path only.

Lori: Right. Absolutely. Viola, your next question on the assistants is how are services for an assistant of surgery reported?

Viola: That's also another good question. Those are reported with the same procedure code, but also what is very important is a modifier that is utilized to distinguish and say that this is an assistant at surgery or a surgical assistant that was present. Modifier AD is used when the assistant at surgery assisted for the majority of the case. Modifier 81 is used when an assistant was utilized for a minimum time in the case. And Modifier 82 is used in an academic institution when a qualified resident surgeon was not available, and this is very important because there are those teaching hospitals that have residents that do perform surgeries and also utilize assistants at surgery when it's necessary. We also have Modifier AS, assistant surgeon, and those are typically used when a PA, nurse practitioner, or CNS is assistant at surgery. I wanna caution that when using the AS Modifier, a modifier from 80, 81, or 82 must also be utilized to also show how much time was utilized for this assistant. Was it, you know, the minimum, the majority of the time? How much time was spent? And most, you know, private payers may use different modifiers. So we do recommend that for the midlevel providers, you do look at your payers, the specific guidelines, so that you report the most appropriate and avoid denials.

Lori: Perfect. Thank you. Elizabeth, our provider is a specialist that is planning a surgical procedure at the request of the patient's primary care doctor. We saw the patient in consultation and made the final decision for surgery last month. Then we brought the patient back three days before surgery to discuss prep, day of instructions, and medication changes. Can we build a second visit as a pre-op visit?

Elizabeth: Ooh, this is such a good question, and we see this all the time in documentation. Ninety-nine percent of the time the answer is going to be no. An E&M service by its very nature has to have a condition to evaluate and manage. And in this case, the decision for surgery, which is the management, has already been made for the condition being evaluated. Additional counseling without a worsening or a new diagnosis does not support medical necessity for an additional service. The flip side of that is going to be if the patient presents with something new that will potentially pose a risk for the surgery, or needs to get under control before we will perform the surgery. Those cases may be subject to billing and additional E&M, but documentation will have to be very concise indicating that that is the case.

Lori: Right. Yes, we do see that quite a bit. Okay, back to you Viola. Can an assistant at surgery or a surgical assistant report services at a teaching hospital? You kind of touched on this a little bit earlier, but what do we do at a teaching hospital?

Viola: Well, there are instances where they can report services they can assist at a surgery, and there are specific rules to when the guideline will apply and when they will receive payment. And one of them is that at a teaching hospital has a training program that has medical residents that are doing surgeries. However, when there are instances when they are not available, or when there are emergency cases, or the skill is needed to furnish a specialized surgery, then the assistants at surgery or surgical assistants are called in to assist in the surgery. And in this case, they can report the services. But as we said earlier, Modifier 82 would need to be utilized to let the payer know that this was an academic institution and we needed this qualified assistant to assist with the surgery and there were circumstances that, you know, a life-threatening situation or emergency that needed their specialized...

Lori: Great. All right, we got time for just a couple more questions here. Elizabeth, I had a surgery case where the gynecology surgeon called in a urology surgeon to help. Each surgeon used CPT code 58662 for 2 separate body areas. An assistant also helped the gynecological surgeon. Can I still bill for the assistant using that same code 58662 with Modifier 80?

Elizabeth: You can, you just need to make sure that the provider will document the reason for having a co-surgeon and an assistant. It's got to be very specific, especially where some Medicare administrative contractors are concerned. They don't want to just see the names of these individuals, they want to see what's being done, and why these extra individuals were needed.

Lori: Right. Absolutely. And Viola, we have a question that came in that's pretty similar to that. What is the proper documentation when billing for an assistant at surgery?

Viola: That is a good question. The proper documentation will be that the surgeon of record is the one responsible for identifying the presence of the assistant surgeon or the assistant at surgery. And also what's even more important is that they detail the work that the assistant at surgery or surgical assistant performed. Mentioning just the name of the assistant surgeon or assistant at surgery is not sufficient. For instance, Palmetto GBA has modified their guidance that says that a documentation requirement is that the surgeon of record needs to put in the body of the note the work that the assistant at surgery has performed, and not just mentioning the name at the heading of the procedure.

Lori: Right. Absolutely. We have a lot of questions about assistants and co-surgeons. It is very confusing, and a lot of it, again, like you've said, it determines what the payer wants, and what side are they in, you know? Or is it a teaching hospital? Or is it just different types of facilities? So, there is a lot of confusion around those types of issues. I think that's all that we have time for today. Thank you, Viola and Elizabeth for answering our questions. If you have questions on this topic or other topics, please go to our website at www.aapc.com\business. Thank you all for joining us and have a great day.

Viola: Thank you for having us.