Anesthesia Coding Alert

Reading descriptor details helps keep claims clean

You can take steps to help reduce the upcoding errors in your practice. Consider this advice from Jann Lienhard, CPC, an anesthesia coding consultant in Marlton, N.J., and Mary Klein, CPC, of Panhandle Anesthesia in Pensacola, Fla.:
 
• Communicate with your providers and educate them continually. "Documentation must be their 'middle name,' and they have to remember it," Lienhard says. "A template might help as a basis for reporting cases, but it's not the catchall."

• Watch the wording of code descriptors. Sometimes just one word or phrase changes the intent of the code, Klein says. Example: A radical mastectomy with node dissection (19220, Mastectomy, radical, including pectoral muscles, axillary and internal mammary lymph nodes [Urban type operation]) crosses to anesthesia code 00406 (Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; radical or modified radical procedures on breast with internal mammary node dissection) with 13 base units. A modified radical mastectomy with node dissection (19240, Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis minor muscle, but excluding pectoralis major muscle) crosses to anesthesia code 00404 (... radical or modified radical procedures on breast) with 5 base units. The change in descriptor wording is slight, but the difference in base units is huge.

• Know your anatomy. Being familiar with anatomy helps you choose from the correct range of codes and narrow your options. Don't be shy about asking your providers if you're unsure of procedures.

• Pool your resources. Take advantage of coding reference books that provide basic descriptions of procedures. Keep up-to-date on coding practices by attending seminars and building a network of fellow coders you can call on for help, either online or in person.