Wiki What is my surgeon referring to?

sinman0531

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I have a surgeon who does a lot of maxillofacial and craniofacial traumas. When he does these, he almost always lists the recommended primary procedure code as
Treat craniofacial fracture - 21236-22 (comminuted)

I have no idea what procedure he is trying to communicate to me. So far I have been able to just attach the 22 to a different procedure code that reflects the majority of the work performed. At first I thought he might be referring to 21336 and just mistyping it, but he usually does more complicated procedures that end up clashing with 21336.

Any help is appreciated!
 
Hi Sinman,
Usually when modifier 22 used the medial record needs to be send with claim as attachment. The payer wants to see what is a bit different...hoping it is in the documentation by the provider.
Lady T
 
We can't really help with this either. Each op report or procedure report would have to stand alone. Attaching a templated (non-existent) CPT code with an automatic 22 every time is just a huge red flag and would not make sense. Every case does not warrant a 22.

Couple questions and comments:
1. Did you ask him? Maybe you should discuss his documentation and give feedback? If you are not comfortable, have you asked a manager or supervisor?
2. What do the actual procedure or surgery reports say?
3. Is he just using a really old and/or outdated template without looking at it and doesn't even realize it says this?
4. 21236 is not a CPT code.
5. "Just attaching" a 22 modifier is not a good procedure.
6. If you break down the report and outline the headers with the body of the op note, do they match? Do they make sense? Is everything accounted for? Does the report even support a 22?
7. Are the claims being denied or rejected or is the provider getting more medical record request than others? Do his claims take longer to pay?
8. Providers listing the actual ICD-10 and CPT codes in reports is not a great practice in my opinion. They need to use words, not codes.
 
1. Did you ask him? Maybe you should discuss his documentation and give feedback? If you are not comfortable, have you asked a manager or supervisor?
Documentation is, unfortunately, not part of my job description when it comes to IP cases (when this appears its always in relation to a complex trauma and he is performing multiple surgeries over days or even weeks).

2. What do the actual procedure or surgery reports say?
This code is "suggested" along with anywhere from 5-15 other procedure codes. Since these are trauma procedures, the documentation can be 4-5 paragraphs, and copying the whole thing would be too risky IMO.

3. Is he just using a really old and/or outdated template without looking at it and doesn't even realize it says this?
He's middle aged.

4. 21236 is not a CPT code.
I know!!! Thats what I am trying to figure out--I'm sure he is referencing a valid code, or maybe even a deleted code, I just have no idea which one.

5. "Just attaching" a 22 modifier is not a good procedure.
I am actually reading the whole op report, and like I said, based on the op report whichever other valid CPT actually describes the majority of the work, I will attach the modifier to if it makes sense. He uses the canned phrases like "there was an extensive amount of work required" or "due to the {insert reason}, the procedure took longer than usual" but sometimes where he puts them doesn't make sense....like he will put it in the paragraph where he's describing 15002/03, and say "due to the presence of eschar, extra surgical time was required" but...that's literally why we are billing the 15002/03 in the first place. His records regularly take me an hour or more because I am reading the op report and comparing it with the integral steps to the procedures to see if the -22 is needed.

6. If you break down the report and outline the headers with the body of the op note, do they match? Do they make sense? Is everything accounted for? Does the report even support a 22?
We don't use headers. If I'm lucky they break up the documentation into paragraphs, but its not uncommon to have 3-4 procedures in a single block of text. See above for the rest.

7. Are the claims being denied or rejected or is the provider getting more medical record request than others? Do his claims take longer to pay?
They did actually email me the other day because his RVU's are sky high...since he is the only one who does MF traumas, it kind of makes sense. I have no way of tracking the A/R side of it in my current job, but based on what I know about other "problem children" I've had in the past in other jobs....he probably does get a lot of record requests.

8. Providers listing the actual ICD-10 and CPT codes in reports is not a great practice in my opinion. They need to use words, not codes.
They use both. Basically they use the lists for themselves, but by no means are the coders handcuffed to their choices (which is nice, because at my last job we were).
 
This seems like a complex issue where you need to bring it to your supervisor or higher management. Other than that, if your job is to 100% abstract the entire case and code it but you have no other expected duties, you would have to code it as you see it in my opinion. Don't even look at the "suggested" codes.
I think bringing a few examples to your supervisor would be the first place to start.
Do you have a query process in your group?
If the RVUs are that high but he's the only one in the group doing those cases, like you said it makes sense. But, if the RVUs are that high in comparison to peers in the same specialty and subspecialty and the same payer mix in the geographic area payers are going to notice.
If you are separated from the A/R side and all the other teams in the revenue cycle it seems like there is not much else you can do other than above suggestions.
 
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