General Surgery Coding Alert

Receiving fair reimbursement requires adequate preparation and documentation

If you've ever filed a claim using an "unlisted-procedure" code, you know how much effort is involved. To ensure that payers properly reward the surgeon's effort (and the coder's work in preparing the claim), our experts offer you three tips. Tip 1: Describe the Procedure in Plain English Anytime you file a claim using an unlisted-procedure code (for example, 37799, Unlisted procedure, vascular surgery; or 43999, Unlisted procedure, stomach), you must submit a full operative report to describe the procedure or service.

Take note: If you're looking for fair reimbursement, however, the operative notes alone won't be enough. You've got to include a separate report that explains in simple, straightforward language exactly what the surgeon did.

Insurers consider claims for unlisted-procedure codes on a case-by-case basis, and they determine payment based on the documentation you provide, says Eric Sandham, CHC, CPC, compliance manager for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno. "Unfortunately, claims reviewers, especially at lower levels, do not have a high level of medical knowledge, and physicians don't always dictate the most accessible notes," he says. Part of the coder's job in preparing the claim is to act as an intermediary between the physician and the claims reviewer, providing a description of the procedure in layman's terms.

"If the person making the payment decision can't understand what the physician did, there's not much chance that the reimbursement you receive will properly reflect the effort involved," says Marvel J. Hammer, RN, CPC, CHCO, owner of MJH Consulting, a healthcare reimbursement consulting firm in Denver.

Keep it simple: Whenever possible, avoid or explain medical jargon and difficult terminology. If appropriate, you may even include diagrams or photographs to help the insurer understand the procedure you are describing with the unlisted-procedure code. "You should try to keep the description short and simple," Hammer says.

Real-world example #1: CPT includes no specific code to describe laparoscopic roux-en-y gastric bypass, so the best code to describe this procedure is 43659 (Unlisted laparoscopy procedure, stomach). When describing this procedure, you should use the surgeon's operative notes as a guide, stressing the main points of the operation and why it was necessary. A sample narrative sent to the payer might read:

Patient suffers from extreme obesity (278.01, Morbid obesity), unresponsive to behavior modification (diet, exercise, etc).

During surgery, the surgeon divides the stomach into upper and lower sections using a cutting surgical stapler. The upper portion of the stomach forms a small pouch. The surgeon bypasses the lower (distal) part of the stomach and the first portion of the small intestine (duodenum and jejunum). The surgeon cuts the small [...]