Gastroenterology Coding Alert

If coding op notes isn't your specialty, these pointers can help.

Some coders thrive on coding operative reports, while others prefer to stick to E/M coding. However, anyone in a busy gastroenterology office will eventually have to do both, so check out these quick tips that can help you perfect your op note reporting.

Tip 1: Don't Just Read the Summary. Read through the entire report every time, rather than just reading the description at the top. The doctor's summary of a diagnosis and procedures at the beginning of the op report doesn't always include all the important details of the procedure, and you could miss a critical detail that differentiates one code from another, or a secondary procedure which could get reported with a second CPT^® code.

Tip 2: Know the Global Surgical Package. While reading an op note, you may come across descriptions of services that you're considering reporting along with the surgery, but before you code them separately, keep in mind what's included in the global surgical package. Most surgeries already include payment for preoperative visits, intraoperative services, postop visits, and postsurgical pain management. However, virtually all GI endoscopic services are "zero day" global services, and would include the evaluation/management same day patient evaluation and immediate post service patient evaluation (including discussion of the findings with patient or family), says Glenn Littenberg MD, a gastroenterologist in Pasadena, Calif.

Tip 3: If You Can't Discern the Code Immediately, Narrow Down Your Options. Once you read the op report, you may not be able to pinpoint the right surgical code immediately, but that doesn't mean all is lost. Create a list of a few codes that might apply, and then cross-reference the descriptors against the op note. If one says it includes fluoroscopic guidance and your op note doesn't mention that, you know you can rule out that code. Do that one by one, and eventually you'll find your code. "When in doubt, ask the physician!" Littenberg advises. "If there is, in fact, no CPT^® code that specifically describes what was performed, use of an unlisted service code may be necessary."