General Surgery Coding Alert

Key: Include an explanatory report to get the payment you deserve. Just because your general surgeon performs a procedure doesn't mean you-re always going to find an exact code descriptor to match it. So what do you do when CPT doesn't have a specific code for a procedure you-re reporting? Turn to unlisted codes -- but make sure you follow these simple steps to show your payer what to do with your unlisted-procedure claim. Step 1: Never Select a -Close But Not Quite- Code You should never report a code that comes close to the procedure your general surgeon performed, but doesn't quite fit. If no precise procedure or service code exists, you should report the service "using the appropriate unlisted procedure or service code," states the CPT Instructions for Use in the CPT manual. CPT includes unlisted-procedure codes to allow you to report procedures for which there is no specific CPT descriptor available. Payment for such claims, however, is not automatic. Your general surgeon must make a careful effort to document the procedure, and the information you include with your claim can make all the difference. Step 2: Explain the Procedure in Layman's Terms Anytime you file a claim using an unlisted-procedure code -- for example, 49659 (Unlisted laparoscopy procedure, hernioplasty, herniorrhaphy, herniotomy) or 39599 (Unlisted procedure, diaphragm) -- you should include a separate report that explains, in simple, straightforward language, exactly what the physician did. Part of your job when coding and 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. You may even want to include diagrams or photographs to help the person reviewing your claim understand the procedure better. "When reporting unlisted codes, I would suggest doing everything you can to make sure you get paid what you think is appropriate," says Denae M. Merrill, CPC-E/M, owner of Merrill Medical Management in Saginaw, Mich. "Overload the payer with information and always give them a way to contact you with questions." Why: Your payers will consider claims with unlisted-procedure codes on a case-by-case basis, and they determine payment based on the documentation you provide. Unfortunately, claims reviewers frequently do not have a high level of medical knowledge, and physicians don't always dictate the most informative notes. If the person making the payment decision doesn't understand what the physician did, your reimbursement probably won't properly reflect the effort involved, says Barbara Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, president of CRN Healthcare Solutions in Tinton Falls, N.J. and senior coder and auditor for The Coding Network. Supply documentation: Since most carriers will no longer accept paper claims, submit your unlisted CPT code electronically [...]