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Authorization code vs coder's code

  1. #1
    Default Authorization code vs coder's code
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    Need help on this one

    Booking was for an excision of a shoulder mass , booking was booked as 11406 with dx as 239.89, with an authorization code

    Now when I code any procedure I look at the operative report, H & P , and Path Report,
    thats it . I coded this as 21930- only because no size dictated in report, AND path report says its a lipoma. Someone in my office told me that I should not code 21930, to change it back to 11406 and it would justify the lipoma also,, and for the authorization. To me 21930 fits more for this procedure, I look at operative report not authorization. Thanks
    a lipoma is a fatty tumor correct?

    PREOPERATIVE DIAGNOSIS: Right back lipoma.

    POSTOPERATIVE DIAGNOSIS: Right back lipoma.

    PROCEDURE PERFORMED: Excision of right back lipoma.

    RESIDENT: _____ (00:34).

    PROCEDURE IN DETAIL: The patient iswas brought to the operating room after appropriate consents were obtained and prepped and draped in the usual sterile fashion. A longitudinal incision was made along Langer’s line after 1% lidocaine was injected and was taken down to the capsule of the lipoma. The lipoma was excised and approximately baseball size when removed. Hemostasis was assured. A 3-0 Vicryl was used for the subcutaneous tissues and a 4-0 Vicryl was used to close the skin in a running fashion. The patient tolerated the procedure well and was transferred to the recovery room in stable condition.

  2. #2
    I agree with you 21930, definitely NOT a 11406... Although, this does look like a great educational opportunity with your provider on documenting size and depth. It sounds like he/she could have done something more extensive than he/she documented.
    Melissa Tescher, CPC, CPMA, CEMC Compliance and Coding Specialist
    Willamette Valley Professional Services member National Advisory Board 2013-2015

  3. #3
    I can talk to these doctors about dictating the size in the operative report till I am blue in the face. It goes out one ear to the other.. No size ,it goes to the lowest code . I talked to them,gave them notes , put signs up by dictation, talked to their office staff, but some still some dont do it. I am just the little guy , but this little guy has yet to give up. Somehow I will find a way to get their attention

  4. #4
    I can definitely sympathize there, some listen, some listen and learn, and some just lean over and snore..... I'm pretty lucky here, I have providers actually wanting to meet with me and those that don't, wsll they get nudged over by their managers. still their focus is usually shortlived. We may be the little guys, but I consider my providers to be like kids...just gotta find the guidance that works best for each.
    Melissa Tescher, CPC, CPMA, CEMC Compliance and Coding Specialist
    Willamette Valley Professional Services member National Advisory Board 2013-2015

  5. #5
    Is this an insurance where you can update the CPT code used? I know some will let you go back and do that, but some you are stuck and they won't update... Good luck, I feel your pain!... alot

    Kristie Stokes, CPC, CPMA, CCS, CMDP, ICDCT-CM

    AAPCCA Board of Directors 2014-2017
    Region 1 - Northeast
    Maine, New Hampshire, Vermont, Massachusetts, Connecticut, Rhode Island, New York

    Today, give a stranger one of your smiles. It might be the only sunshine they see all day.

  6. #6
    Usually we get denied then re summit it with operative report and usually get paid, at least thats my understanding
    Last edited by codedog; 12-06-2011 at 10:40 AM.

  7. #7
    We have our providers advise our surgery schedulers which codes they anticipate using for the procedures being set up and an authorization is requested accordingly. We advise the docs that if the code changes, they must notify us within 24 hours so that we can contact the carrier and update the codes on the authorization. Some carriers will do so, some will not, or have a very small window to modify an authorization retroactively. Some plans will reprocess a claim and allow payment once you've explained why the codes don't match (you never know what the providers will encounter once they actually hit the OR). It only took several large claims being denied for an auth mismatch, then appealed, and denied on appeal, for the docs to all get on board with this process Of course, as always, there are still those instances where everything gets dropped and it's a fight to get things done
    C. Cameron, CPC
    Billing & Coding Manager

  8. #8
    Problem I have here is doctor's office books most case in the Integumentary section 11400 -11446 ,when operative gets to me ,I tend to want to code in the Musculoskeletal system, happens alot , more than ever .

  9. #9
    Dont forget you can use the size on the path. However that is the last resort because it shrinks. That would constitute the smallest size. I think its a problem across the board everywhere! I agree with your code I would not code from the integ. I always knew what sports my docs were into ( size of a golfball, hockey stick incision, size of a baseball, size of a small tennis ball, in the shape of a football.... etc lol

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