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Gastroenterology Coding Alert

Coders Must Provide Last Line Of Documentation Defense

Published on Wed Sep 08, 2004

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 of obstruction) to 43255 to show that the injection was performed on the ulcer.

    Payoff: If you file this claim properly, the tumor removal code (43251) should be reimbursed in full, and the control of bleeding (43255) should be paid at a reduced rate.
        
    Note: The reduced rate will be up to the insurer.

    Documentation Must Prove Separate Site

    In the above example, you must prove through documentation that the same physician  performed the polyp removal and the injection at different sites - or the insurance company will bundle 43255 into 43251.
     
    Why? Without evidence of separate sites, the payer will assume that the gastro caused the bleeding during the polyp removal and will deny 43255.
     
    Prevent this problem by including data proving the doctor treated two different duodenal problems. The report should be extremely detailed, says Janene Long, billing administrator at Gastroenterology-Hepatology Associates in Reading, Pa.
     
    "Legible notes are important, but they should also be very thorough. Whatever the doctor is thinking and doing should be documented, even if it is just a minor detail,"  Long says.
     
    Example: The gastro may document the point in the procedure when he discovered the duodenal ulcer. This discovery should be included in the claim. "The more information you have, the better. I would always rather have too much than not enough," Long says.

    Do Dictation and Report Match?

    Long always goes the extra mile by making sure the dictated report matches the handwritten report. If she notices any inconsistencies between the dictation and the report, she's sure to clear it up before mailing the claim.

    Don't Forget Diagnosis Codes 

    You should also make sure that the diagnosis codes match up with the procedure codes, Quicker says. In a fast-paced office, ICD-9 codes can be forgotten on claims if you don't diligently check for them. 

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