General Surgery Coding Alert

Documentation:

Don’t Let ‘Authorization’ Lead Code Selection

Published on Fri Jun 16, 2023

Undercoding can cost you.

When a scheduled surgical procedure takes an unexpected turn that involves additional services, your coding needs to take the turn, too.

Problem: In order to save time and money, some medical practices may opt to only seek prior authorization, and therefore, code for services they know will definitely occur during a patient encounter.

That can lead to undercoding, a common occurrence that can cause both professional and financial woes. Not only can you lose the payment your surgeon deserves, but you can also misrepresent the patient’s condition and open your practice to fraud charges.

Read on to understand why precise coding matters, as well as ways to avoid accidental undercoding.

Consider the Costs of Undercoding This Encounter

The case: A patient at your practice requires an endoscopy, and you seek and receive prior authorization for the service. While the provider is performing the endoscopy, they realize that the situation requires a biopsy — for which no one sought prior authorization. If you code this situation according to the prior authorization, you are undercoding the encounter.

That can have an impact on patient care and further treatment. Let’s say you did code just the endoscopy, but then the patient’s biopsy comes back positive for cancer.

Now the patient needs more surgery and more inpatient or other facility stay, but there’s no record for a biopsy, even though you have a pathology report, which doesn’t match what was reported by the surgeon, explains Terry Fletcher, BS, CPC, CCC, CEMC, SCP-CA, ACS-CA, CCS-P, CCS, CMSCS, CMCS, CMC, QMGC, QMCRC, owner of Terry Fletcher Consulting Inc. and consultant, auditor, educator, author, and podcaster at Code Cast, in Laguna Niguel, California.

This could lead to a payer wondering how you found out about the cancer from an endoscopy alone and how you got a pathology report. It could confound the medical record, which is vital to patient care.

Pay: Failure to report the biopsy could also cost your surgeon deserved payment. For instance, a diagnostic colonoscopy, code 45378 (Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)) pays $183.67, while a colonoscopy with biopsy, code 45380 (Colonoscopy, flexible; with biopsy, single or multiple) pays $199.60 (2023 Medicare Physician Fee Schedule facility national payment amount, conversion factor (CF) 33.8872).

Know That Undercoding Can Be Fraudulent

The scary f-word in healthcare is fraud, which the Centers for Medicare & Medicaid Services (CMS) defines as “an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person.”

Undercoding the above case could result in the patient having a lower deductible payment and out of pocket expense. If you think that’s a good thing for your practice, think again.

A payer or auditor could claim that the surgeon intentionally reports a lower level of service as a financial incentive to the patient. That could subject your practice to civil penalties under the False Claims Act.

Prioritize Accuracy for Patient and Pay

As a coder, you know that your efforts do a lot to dictate a patient’s narrative of health and illness; you provide an official record of their condition. Therefore, making sure your code choices reflect the patient’s specific situation is crucial for myriad reasons.

“It’s important to make sure that we code accurately. Downcoding, undercoding, trying to capture it just for money is wrong. You may find yourself in a really compromised situation,” Fletcher warns.

Of course, coders who intentionally undercode may think they’re doing something helpful, either by avoiding expense for a patient or a payer or trying to avoid a mistake made in a prior authorization. “Coding lower to avoid problems is an old school mentality to avoid problems, but CMS has been clear that any inaccurate coding, high or low, is inappropriate,” says Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/credentialing/ auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California.

Don’t forget: “The medical records are a history of what was addressed and treated during the visit. If the documentation is too vague to code, then most likely there are significant gaps in the documentation that need to be addressed to have an accurate record of what occurred,” Johnson continues.

Undercoding can be accidental, but it still carries the potential for big consequences. Here are some pointers on how you can strive for accuracy every time.

Stay up to date: Coders have a responsibility to keep informed about the latest industry changes, including updates to guidelines and regulations. The more you know, the easier it is to assign the correct codes.
Thoroughly review documentation: Carefully read the documentation, including medical notes, lab results, and imaging studies. This will help ensure you capture all the services provided.
Be specific: The more specific the code, the better it reflects the service(s) provided.
Know payer policies: Different payers have different requirements, so familiarize yourself with these policies and contact the payer directly whenever you have a question about how to properly submit a claim.

Also, check with the payer providing the prior authorization to see if it will approve a range or series of CPT^®codes that reflect a reasonable expectation of what your provider might do. This will help avoid having to appeal a denial. For instance, instead of getting pre-auth for 43235 (Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)), get approval for 43235 and 43239 (Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple) up front to cover biopsy done during upper GI endoscopy, or as broad a range of EGD codes the payer would preauthorize.

Communicate and educate: Always keep an open line of communication with your healthcare providers to clarify any questions or concerns about proper coding. The goal is to accurately reflect the services provided. As a coder, you’re the expert and may have to occasionally review guidelines and regulations with the providers to help them improve their documentation.