Urology Coding Alert

Question: Our ASC requires the urologist to dictate his CPT Codes directly into the op report. They tell us that this way, the surgeon and the ASC are sure to report the same code as one another. Our surgeon doesn’t always select the correct code, so I’m uneasy about this. Should we follow the ASC’s advice?

Answer: “I don’t think this is a good idea for many reasons,” says Lisa Weston-Powell, CPC-H, LHRM, director of ambulatory surgery coding services at The Coding Network LLC. “The coder will still have to read the report and assign codes based on what is documented and not what codes are dictated.”

Because the ASC and the surgeon must report the same code, it can be unsafe to rely solely on the surgeon’s code selection.
 
The problem: The ASC might report the code that the surgeon dictates, while the physician’s office will bill a code based on the coder’s assessment of the documentation. In many cases, the physician’s coder will select a different code than the surgeon dictated, which means that the ASC and surgeon’s office will bill separate codes. In those cases, Medicare will deny payment for the service to the ASC.

Best bet: Coordinate your billing and coding choices with the ASC to ensure that both are reporting accurate and matching codes.