Gastroenterology Coding Alert

Prove separate site before mailing modifier -59 claim As a coder in a busy gastro office, you must make sure to include the proper documentation with every claim, even if that means delaying a claim to get a doctor's approval on a code. It may be difficult - and even uncomfortable - to demand so much documentation from your doctors, but consistently precise op notes lead to consistently reimbursed claims.
 
In any gastro office, "documentation must be legible and accurate enough to withstand an audit," says Diana Quicker, medical coder for a four-doctor gastro practice in Sarasota, Fla.
 
Whenever Quicker gets an operative report with illegible or incomplete information, she finds the physician and gently reminds him: "I wasn't in the room during the procedure, and I didn't round with you. The more you tell me, the more accurately I can code," she says. Bad Documents Really Hurt in Court No matter what your method, you should clear up any documentation issues in your office immediately.
 We all know that bad documentation can lead to wasted time and resources, denials and audits, but sloppy records can also reveal legal vulnerabilities, says Susan Manning, JD, of the Wisconsin Medical Society.
  
If a patient sues one of your practice's doctors, bad patient documentation can spell doom. "I can't imagine what a litigating attorney would want more than an illegible patient document. The attorney holds it up to the jury, the jury can't read it, the office is fried," Manning said at April's American Academy of Professional Coders (AAPC) conference in Atlanta.
 
Read on to see how some expert coders head off any compliance nightmares by reporting accurately and completely on every claim.  Double Duodenal Procedure Demands Accurate Notes Solid documentation should be a priority with every claim, and it is essential when coding scenarios in which the doctor performs a pair of procedures and you want payment for both of them. To illustrate this point, consider the following example of a strong claim that includes multiple procedures.

Let's say the gastro removes a polyp from a patient's duodenum using snare technique. While performing the procedure, the doctor notices an acute, bleeding ulcer in a different part of the duodenum. He performs a control-of-bleeding injection on the ulcer before wrapping up the session.   ICD-9 Code Alerts Payer To Ulcer To give this claim the best chance of acceptance, you should:
  report 43251 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with  removal of tumor[s], polyp[s] or other lesion[s] by snare technique) for the polyp removal.
  append modifier -59 (Distinct procedural service)   
 to 43255 (... with control of bleeding, any method) for the bleeding ulcer injection.
  attach ICD-9 code 532.00 (Duodenal ulcer; acute with hemorrhage; without mention [...]