Use CPT Terminology To Ensure Correct Coding
Published on Wed Aug 01, 2001
Otolaryngologists have long been urged to document all procedures performed to ensure fair and appropriate payment for their services. It is just as important, however, to use CPT terminology when listing those procedures at the top of an operative report.
"The physicians who dictate best not only list all the procedures at the top of the op note, but also use clear, CPT-style language that any coder, experienced or not, can read," says Randa Blackwell, coding and reimbursement specialist for the department of otolaryngology at the University of Maryland in Baltimore.
This can be difficult, however, because the words used to describe procedures and conditions in CPT and ICD-9 can differ from the clinical terminology otolaryngologists and other physicians have been trained to use, Blackwell says.
Although coders should always read the entire operative report, especially the procedure notes, many do not or cannot do so for a variety of reasons (such as time constraints). In some practices, Blackwell notes, coders do not see the operative report at all.
As a result, the otolaryngologist's terminology takes on additional importance. "If the otolaryngologist doesn't dictate in CPT/ICD-9 language, inexperienced coders lose their point of reference. Without CPT language to follow, everybody is lost."
This, in turn, can result in difficulty training staff, loss of revenue, audits, delays in getting bills out and denials by carriers.
"An inexperienced coder may be confused trying to graft clinical descriptions onto CPT or ICD-9 codes that seem to describe different conditions or services," says Barbara Cobuzzi, MBA, CPC, CPC-H, a coding and reimbursement specialist and president of Cash Flow Solutions, in Lakewood, N.J. "A simple terminology mixup can easily lead to billing errors."
Example 1: Endoscopic Sinus Surgery
In an operative report Cobuzzi reviewed recently, the otolaryngologist listed the following procedures at the top:
Bilateral total endoscopic ethmoidectomy.
Bilateral maxillary antrostomy with tissue removal.
Bilateral sphenoid sinusotomy.
Left frontal sinusotomy.
"An experienced coder would assume that all the procedures were performed endoscopically, and would confirm that by looking at the procedure notes in the op report," Cobuzzi says. "But the inexperienced coder, guided mainly by the CPT book, might note that only the first procedure mentions endoscopy."
This initial impression could be reinforced by the use of the word "sinusotomy" in the sphenoid and frontal procedures, Cobuzzi notes. "The only codes in CPT that specifically mention "sinusotomy" are open sinus surgery codes. Billers unfamiliar with endoscopic procedures might follow what they see in the book and bill open sphenoid and frontal sinusotomies."
Note: CPT includes 14 open surgical codes described as sinusotomies: 31020, 31030, 31032, and 31050-31090.
The otolaryngologist should have listed the procedures as follows, Cobuzzi says:
Endoscopic total ethmoidectomy; bilateral (31255-50)
Endoscopic maxillary antrostomy with removal of tissue from maxillary sinus; bilateral [...]
