General Surgery Coding Alert

Give your surgeon the right tools.

If it’s not documented, it wasn’t done… or so the saying goes. When it comes to general surgery coding from an op report, you can take that to the bank. 

With new CPT® 2014 codes firmly under your belt and ICD-10 implementation bearing down on you, now is a great time to focus on documentation that can help you earn all the pay you deserve and avoid audit problems — or even fraud charges. 

ICD-10 and CPT® Require Details

Whether assigning a diagnosis or procedure code, you’ll need specific information from the op report to choose the right code.

Under ICD-10, physicians will need to beef up their documentation, according to Arlene Maxim, RN founder of A.D. Maxim Consulting, A.D. Maxim Seminars, and The National Coding Center, in Troy, Mich. “Documentation will make or break this process,” says Maxim, because ICD-10 will require a higher degree of specificity. 

Reporting surgery procedures also requires detailed information. For instance, to choose the correct procedure code for a breast biopsy, you’ll need to know if the surgeon performs an open incisional or percutaneous needle core procedure, plus a host of details such as whether and what type of imaging is used, whether the surgeon places breast localization devices, etc. 

Documentation is key: Clinical documentation is the foundation of every health record, according to Dorothy D. Steed, CPC-H, CHCC, CPUM, CPUR, CPHM, ACS-OP, CCS-P, RCC, CPMA, RMC, CEMC, CPC-I, CFPC, PCS, FCS, CPAR, AHIMA Approved ICD-10 Trainer, an independent healthcare consultant and educator in Atlanta, Ga. 

Clinicians may collect documentation only once, but others will use it many times, said Steed during the recent audio conference “Clinical Documentation Improvement” sponsored by The Coding Institute affiliate AudioEducator.com. The “coder needs high quality documentation to ensure coding quality and accuracy,” she said.

Check These Documentation Criteria

Here are seven criteria for quality documentation. Make sure your surgeons’ record keeping will pass muster with these expert tips.

1. Legibility: Documentation should be readable and easily deciphered, but a lot of handwritten documentation isn’t, Steed cautioned. Complete and legible entries provide protection for providers. But illegible entries in a medical record may cause:

• Misunderstanding of a patient’s condition
• Jeopardized reimbursement
• Denied payment
• Loss of legal appeals.

Remember: Legibility doesn’t just refer to handwriting — an electronic record isn’t “legible” if the words filled into blanks don’t make sense, even if you can read the words. Also note that 

A legible note includes being able to read the name and title of the physician completing the documentation.

2. Reliability: The documentation should support the rationale for the diagnosis and medical necessity for the procedure. If it doesn’t, you should question the reliability of the note and ask the surgeon for clarification.

Most denials and down coding occur when at least part of the documentation doesn’t support the codes you report.

3. Precision: Clinical documentation must be exact, and strictly defined. Make sure your surgeon uses terms precisely, such as using “biopsy” to refer to tissue samples taken for diagnosis with no attempt to remove an entire lesion and reserving “resection” or “excision” for procedures that extract all or part of an organ or region of diseased tissue.

4. Completeness: Good documentation fully addresses all necessary items, including complete patient information, procedure description, diagnosis statement, and physician identification. 

5. Consistency: Documentation shouldn’t be contradictory. If there are conflicting statements in the record, such as the use of the term “biopsy” in an op note that identifies and requests review of specific margins, you need to get to the bottom of it. Coding for a biopsy when the surgeon actually performed a resection could cost your practice. 

6. Clarity: Documentation should be unambiguous. Op reports using vague descriptions such as “closed surgical site” instead of a specific statement such as “performed layered closure” won’t support the services your surgeon provides.

7. Timeliness: Documentation must be up to date to help ensure optimal patient treatment.

Example: The surgeon titles the op report “breast biopsy,” but the op report states, “removed breast lesion with wide margins involving lower inner quadrant, placing sutures at 12, 4 and 8 o’clock for margin evaluation,” which describes a quadrantectomy. 

Solution: The contradiction makes this difficult to code, but you’d be hard pressed in an audit to defend anything but (19101, Biopsy of breast; open, incisional) for this service because it is clearly labeled “breast biopsy.” 

By asking the surgeon to clarify the discrepancy and update the op note, you may have sufficient documentation to code (19301, Mastectomy, partial [e.g., lumpectomy, tylectomy, quadrantectomy, segmentectomy]).

The difference is significant. 19101 pays $223.89, while 19301 pays $661.29 (Medicare Physician Fee Schedule national facility amounts, conversion factor 35.8228).