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Anesthesia Coding Alert

Check Yourself:

Ask Pointed Questions to Help Determine Codes

Published on Thu May 25, 2006

Correct claims can boil down to location and approach

Verifying the procedure location and surgical approach are two keys to correct anesthesia coding. Ask yourself these questions from Samantha Mullins, CPC, MCS-P, ACS-AN, manager of coding and compliance with VitalMed in Birmingham, Ala., to ensure you choose the best option for each scenario:
 

  • What body area is involved? Extremity (upper or lower?); skin (where on the body?); abdomen (upper or lower?). Getting op notes or other documentation can usually give you all the details needed to determine the correct anatomic location.

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  • What surgical approach was used? Was the approach laparoscopic, thorascopic or endoscopic? Was the approach laparotomy, thoracotomy or another incision? Was the patient's position prone, supine, beach chair or other?

    • Familiarizing yourself with common medical terms offers more coding clues. For example:
     

  • "Distal incision" denotes an incision that is away from the body's center (such as from the wrist to the finger tip).


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  • "Upon entrance the liver was viewed" " Because of the liver's location, this type of phrase identifies a procedure either within the upper abdomen or within the lower thoracic cavity.

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  • "An incision was made lateral to the umbilicus and taken in a cephalic direction" This notes an incision on the side and in an upward direction.

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