Coding Case Study:
Proper Documentation Crucial To Increased Reimbursement
Published on Wed Dec 01, 1999
Poor documentation by cardiologists places limits on how well insurance carriers will reimburse for a procedure. With specific dictation and precise operative notes, however, cardiologists can expect higher payment rates.
In the following case study, the cardiologist performed a non-coronary procedure but combined an unusual format with an unclear procedure report. Because the operative note makes it difficult to know exactly what occurred during the surgery, some key reimbursement opportunities have been missed.
Operative Report
1. Occluded left common femoral artery successfully
treated by Angio-Jet thrombectomy and balloon
angioplasty.
2. Occlusion of the left superficial femoral artery.
Procedure: Left lower extremity angioplasty. Angio-Jet thrombectomy. Percutaneous transluminal angioplasty.
Method: Written informed consent was obtained. Modified Seldinger technique was used to place a 6 Fr sheath into the right femoral artery. A 5 Fig-TR catheter was used along with an 035 angled Glidewire to gain contralateral access. Angiography was performed of the left iliac artery. The patient received 5,000 units untravenous Heparin. The sheath was exchanged for a 6 Balkin sheath. A 14 BMW wire was then introduced but could not be advanced across the occlusion. It was exchanged for a V-18 control wire, which was successfully used in conjunction with this wire. Angiography was performed in the distal vessel, and Angio-Jet, E-train catheter was then used for thrombectomy.
The Angio-Jet was removed and a 4/2 Opta LP was used to perform balloon angioplasty after exchanging the wire for a Magic Torque. Additional inflations were performed using a 5x2 Opta LP at five atmospheres. Attempts were then made to traverse an occlusion in the left superficial femoral artery using both a multipurpose catheter and a variety of wires; none of these could be advanced into the occlusion in the superficial femoral artery. The sheath was withdrawn, adequate hemostasis was achieved and there were no complications.
Angiography: Initial angiograms demonstrated a normal appearing distal left external iliac artery. The common femoral artery was occluded. After treatment with the Angio-Jet and angioplasty, there was a 20 percent residual in the common femoral artery. The profunds was normal. The superficial femoral was occluded in its proximal position. There was distal reconstitution of the vessel through collateral flow. The popliteal had plaque disease. The anterior tibial appeared normal in its proximal portion, as did the posterior tibial and peroneal. The tibioperoneal trunk was normal.
Comment: Patient is a 49-year-old female who recently underwent coronary intervention using a left groin approach. An Angio-Seal closure was used. Shortly after the procedure, she experienced leg pain. She will return in approximately one month to have an attempt to open the superficial femoral artery from a popliteal approach.
Unclear Documentation Limits Pay Up
Although the operative [...]
