Wiki Procedure section vs Findings section for reimbursement

[BS&SC]

Finally landed a job as a billing specialist, which I have found does require some tweaking of codes, so that is both good...and a struggle for me. Hard because no one else, to my knowledge, has a CPC, and I tend to come at things more from a coding and medical necessity perspective than a let's-get-paid. Anyway, a couple of days ago, I found a fee ticket billing for an E&M code when the patient was taken into the COLPO room for a colposcopy. I felt pretty confident in not allowing the E&M to be billed due to lack of documentation.

On the same ticket, they coded two separate procedures, one for a bx of the vaginal endometrium and the other for a bx of the vulva. I didn't feel like I could code the vulvular bx because the PROCEDURE section of the report does not state anything about the work done for the vulvular biopsy, just the endometrial bx. However, in the FINDINGS section, it mentions the bx of the endometrium and the biopsy of the vulva. Should I allow the CPT code for the reimbursement of the vulva bx despite lack of support for it in the PROCEDURE section? Then, today, after reviewing this again, we discovered that the path for the vulvular biopsy was canceled.

This probably should be pretty straight forward, but as the newbie, I find myself constantly questioning my "training."

 

[csperoni]

I would say the 2 most likely situations here come down to some incorrect or vague documentation. Which you will find all the time. The best situation is to query the clinician and politely request the note be amended so you can code correctly for all work that was done and get accurate payment.
I assume either:
1) They took specimens from both the endometrium and the vulva, but did not adequately document in the procedure section.
2) They took specimen from only the endometrium and incorrectly also checked off a box for the vulva.
If both were done, and they are not NCCI edits, then both should be billed.
Regarding the E/M, it is possible an E/M was also performed on the same day as a colpo. It must be documented, but does not need to be a separate note than the colpo note. For example, if it was a new patient who was evaluated, records reviewed, etc., and THEN the decision for colpo was made, E/M is appropriate with -25. If there were other problems addressed: patient wanted to discuss birth control options, patient has a UTI, etc, E/M is appropriate with -25.
If the patient was seen last week for a PAP, result came back abnormal and patient was instructed to return for a colpo, an E/M is not appropriate.

 

[BS&SC]

Thank you, csperoni!