Case Study:
Payment for Atypical Procedures Demands Operative Note Clarity
Published on Wed Nov 01, 2000
"The notion that procedures should never be billed solely on the listed procedures at the top of the operative report is well established among coding specialists. Therefore, these specialists routinely recommend that coders read the entire operative note to accurately assess which procedures were performed and should be billed. This coding truism applies even more when the procedures performed were unusual or the procedures are not listed in the CPT manual.
Sometimes, however, the procedure notes in the operative report shed little additional light on what the otolaryngologist did. When dealing with insufficient or weak documentation, coders have two options: the otolaryngologist can be asked to provide an addendum to the operative note or the operative session must be billed based on the documentation available.
In the case study that follows, the otolaryngologist lists a bilateral tympanostomy as well as a partial myringectomy on the right side. There is no code for excising part of the tympanic membrane and because the otolaryngologist does not clarify how the excision related to the placement of tubes in the same ear, the coder may have difficulty selecting the correct codes when billing for the session.
Operative Report
Procedures: Bilateral myringotomy with ventilation tube placement, adenoidectomy and partial myringectomy of the left tympanic membrane.
Preoperative Diagnosis: Persistent eustachian tube dysfunction, chronic mucoid otitis media and adenoid hypertrophy.
Postoperative Diagnosis: Same
Indications: This is a 2-1/2-year-old white male who has had persistent eustachian tube problems and had a previous set of ventilation tubes to treat recurrent bouts of acute otitis media. Since those tubes have extruded, the patient has redeveloped a tendency for persistent middle ear fluid, retraction of the tympanic membrane and recurrent otitis media episodes. The patient is brought to surgery at this time for replacement of ventilation tubes. The weakened portion of the tympanic membranes may have to be addressed by partial myringectomy. The adenoid pad is to be removed because of the statistical advantage in cases of multiple sets of ventilation tubes.
Description of Procedure: There was a large amount of cerumen and debris that was aggregated around an extruded ventilation tube. The tube and the surrounding debris were removed. The tympanic membrane was intact, with ballooning of the anterior superior portion of the tympanic membrane outwardly under the influence of nitrous oxide. The area in question is severely atrophic. When the myringotomy was made this area became quite redundant. Decision made to resect the weakened area. This left approximately a 15 percent anterior superior tympanic membrane perforation. An Activet T-gromet ventilation tube was modified by removing [...]
