Otolaryngology Coding Alert

Otolaryngologists need to be specific and accurate when dictating their operative notes. This means that procedures listed at the top of the operative report should be documented in the procedure notes that follow, and that any procedure documented in the body of the operative report also should be listed at the top. Otherwise, coders may not be aware of which procedures to bill, and physicians may not receive full reimbursement.

Procedures listed at the top but not described in the body of the operative report are presumed not to have been performednot written, not done is the rule to follow in these cases. If a procedure is described in the procedure notes but not at the top, the otolaryngologist is depending on the coders ability to glean which procedures actually were performed.

Operative reports also should have a Findings section that includes such items as the size of any lesion that was excised and the size of the wound after the excision, says Lee Eisenberg, MD, an otolaryngologist in Englewood, N.J., and a member of CPTs executive committee.

The following operative report, which describes a number of procedures performed on an 82-year-old woman, illustrates how the failure to specifically and accurately describe procedures performed results in reduced reimbursement. Otolaryngologists also should remember that improperly described procedures that are billed may be vulnerable to a future audit.

Initial Operative Report

Preoperative Diagnosis: Squamous cell carcinoma, floor of mouth.

Postoperative Diagnosis: Squamous cell carcinoma, floor of mouth.

Operation: Partial glossectomy, full thickness skin graft from chest wall.

Operative Findings: This is an 82-year-old woman who presented one year ago with diffuse leukoplakia on the ventral surface of the anterior third of her tongue on the left side, extending toward the floor of the mouth.

Biopsies were taken, which were negative for cancer. She was referred to an oral surgeon for carbon dioxide laser vaporization of the entire mucosa. This was performed without incident in his office and healing was uneventful.

She subsequently developed a lesion at the junction of the ventral floor of the mouth and tongue, which on biopsy proved to be a superficial squamous cell cancer. At surgery she was noted to have an area of irregular mucosa posterior to the biopsy site on the ventral surface of the tongue, which was biopsied. Frozen section diagnosis was benign. The tumor itself had a gross diameter of more than 1 cm with irregularity and induration on the mucosa but without palpable evidence of deeper invasion. No neck nodes were palpable.

Procedure: With the patient in the supine position under general nasotracheal anesthesia, the oropharynx was packed with a large sponge, soaked in saline for protection of the endotracheal tube during the [...]