General Surgery Coding Alert

For a variety of reasons, many general surgeons pay scant attention to the documentation supporting the evaluation and management (E/M) services they perform. But with improved documentation, if your surgeons were able to report one level of service higher to match what the documentation, properly written, actually supports, they could earn $40,000 or more annually without fear of audit, coding experts say.

General surgeons often complain they are working harder and making less money than ever, says Arlene Morrow, CPC, a general surgery coding and reimbursement specialist in Tampa, Fla. I hear this every day from the surgeons I work with, Morrow says, and I always tell them the same thing: The only area of medical practice in which increased payment is possible is E/M; it just isnt happening in surgery. So they need to invest their time in something that will yield a return.

M. Trayser Dunaway, MD, a general surgeon in Camden, S.C., and author of Pocket Guide to Clinical Coding, concurs. I noticed I was being paid less and less for procedures and more for E/M and paperwork. So surgeons should take their lead from that.

Take an Active Role

Getting paid more for E/M doesnt just happen, however, Morrow says. To accomplish this, surgeons need to take an active role in determining and documenting the level of E/M they provide to their patients. But general surgeons have not been trained in this area, Dunaway says. We go in and say to ourselves, How tricky was this? It was more than a level one, but not the trickiest (level five), and then basically choose among levels two, three and four, based on a feeling about how much time is spent with the patient and how sick he or she is. And we or our office often will undercode just to avoid an audit, he says. If the documentation we write down doesnt support a higher level of code, our staff can just code what they see.

Not only is undercoding a poor reimbursement strategy, in some cases it results in fines being levied against physicians for not providing (or not documenting that they provided) adequate care to patients.

The good news is, documenting correctly doesnt necessarily mean documenting more. In many instances, surgeons may be able to document less, but do it better. Many surgeons believe that documenting correctly involves more paperwork, but usually, its the opposite, Morrow says. Physicians tend not to give concise documentation. The fact is, if they format their documentation, often it will cut down both on the time spent documenting and on the high cost of transcribing the documentation. For example, she says, a large 50-surgeon practice spent $500,000 annually on transcription, [...]