General Surgery Coding Alert

Surgery practices require protocols that guide the entire coding, billing and reimbursement process. Such protocols can prevent coding errors and provide strategies for dealing with reimbursement problems. Many protocols can optimize efficiency and stay within correct coding parameters. Some of the more important protocols follow:
 
1. Review codes and modifiers and revise when necessary. Although surgeons are ultimately responsible for coding decisions, coders and other billing staff may be asked to modify or even select CPT and ICD-9 codes. A member of the coding or billing staff should be responsible for comparing the surgeon's documentation to the information on the form when claims are filed. This helps to ensure that all services being claimed are documented, all bundling guidelines have been followed, any appropriate modifiers have been used and the procedures and services being claimed are listed properly.
 
Example: The surgeon removes a Medicare patient's appendix and lists the following procedures: 49000 (exploratory laparotomy, exploratory celiotomy with or without biopsy[s] [separate procedure]), 44005 (enterolysis [freeing of intestinal adhesions] [separate procedure]) and 44950 (appendectomy). Although the surgeon has assigned these codes, the coder reviews the claim and determines that the laparotomy and the lysis of adhesions are bundled with the appendectomy and should not be billed separately.
 
Example: Two weeks later, while in the appendectomy's 90-day global period, the patient has a fever and shows signs of infection. The surgeon takes the patient back to the operating room and reopens the abdomen to deal with the infection. On the form, the surgeon has billed 49002 (reopening of recent laparotomy) without a modifier. The individual responsible for checking and revising codes adds modifier -78 (return to the operating room for a related procedure during the postoperative period), without which the claim likely would be denied.
 
2. Ask the physician for an addendum if documentation is inadequate. Coding and billing personnel who check codes and modifiers for accuracy must ensure that the surgeon's documentation supports the procedures being billed, says Arlene Morrow, CPC, CCC, a general surgery coding and compliance specialist in Tampa, Fla. If the documentation is vague or incomplete, the surgeon must complete or revise the patient's chart as necessary, Morrow adds, noting that the conditions for adding or revising documentation must be followed.
 
Example: The surgeon performs an examination and determines that an established patient has a bowel obstruction. The surgeon bills 99214 (established patient office visit) for the E/M service provided. Upon review of the documentation, however, the coder discovers that the documentation does not support such a high-level visit. In this situation, the individual who reviewed the claim (or another coding or billing staff member) should question the surgeon about the visit, Morrow says. If a Level Four visit was performed but not [...]