General Surgery Coding Alert

Extract code from surgeon's narrative description.

If your surgeon fails to indicate the ICD-9 code for the condition he treated, you don't always have to talk to him before you file a claim. Sometimes you can read the documentation yourself and urn a verbal report into code.

Crack the Notes to Pick the Code

Suppose your surgeon hands you a superbill with the procedures circled and the diagnosis left blank. You could ask the physician which diagnosis to report, or you could examine the documentation yourself. If your office has a policy that includes "coding by abstraction" by certified/qualified coders, then submitting charges based on what is supported (documented) in the note is appropriate, says Barbara J. Cobuzzi, MBA, CPC, CPCH,CPC-P, CENTC, CHCC, with CRN Healthcare Solutions in Tinton Falls, N.J. The physician should be signing off on these charges as part of your internal policy.

Some practices choose to review the documentation and compare it against any diagnoses recorded on the superbill, even when they aren't required to. This ensures that the documentation matches the code selection every time. When in Doubt, Confirm With the Surgeon If you are new at coding diagnoses from the surgeon's notes, you should double-check your code selections with the physician before submitting your claims.

"Until a coder feels comfortable with the ICD-9 books and the codes used more often in their office, it's a good idea to run the choices by a clinician," says Suzan Berman, CPC, CEMC, CEDC, senior manager of coding and compliance with the Physician Services Division of UPMC in Pittsburgh. You never want to give a patient a disease or symptom they don't have -- or one more severe (or less) than what they have."

Also, checking with physicians provides them feedback.

Doing so can help them learn how to better document patient condition in the notes so you won't need to ask next time.

Tip: Make sure your office creates a written policy that spells out what coders should do in the absence of an ICD-9 code. Some physicians prefer that you ask them for information, while most others rely on their coders to select an accurate code. Check Out This Example Consider the following situation in which the coder must fill the gap when the surgeon doesn't provide an ICD-9 code.

Example: The surgeon's report shows he performed an initial repair of an inguinal hernia for a 22 year-old patient with a strangulated hernia (49507, Repair initial inguinal hernia, age 5 years or older; incarcerated or strangulated). But the report doesn't provide an ICD-9 code.

First step: Refer to the op note for any further description. For instance, the surgeon's description states that the hernia sac contained sliding components of bowel on the left side of the midline and is "irreducible."

Next step: Look up "hernia, inguinal" in ICD-9 Vol. 2 and select the indented "with" obstruction (550.1, Inguinal hernia, with obstruction, without mention of gangrene). Turn to Vol. 1 and read the information under 550.1, including the definition, "with mention of incarceration, irreducibility or strangulation," which confirms you're on the right track. Finally, notice that 550.1 requires a fifth digit. Because the surgeon described a one-sided hernia, you should select the fifth digit for "unilateral." And because the surgeon's note indicated that this was the initial surgery, you can assign the fifth digit as "0," (Unilateral or unspecified [not specified as recurrent]).

Bottom line: The correct ICD-9 code for this case is 550.10 (Inguinal hernia, with obstruction, without mention of gangrene, unilateral or unspecified [not specified as recurrent]).