General Surgery Coding Alert

Thorough knowledge and use of modifiers and diagnosis codes are key to efficient billing and reimbursement, says Kathleen Mueller, RN, CPC, CCS-P, a general surgery coding and reimbursement specialist in Lenzburg, Ill.
 
"Carriers deny claims for a lot of different reasons," Mueller says, "but the majority of denials are the result of incorrect modifier use and the wrong ICD-9 code."
 
You can improve coding by consulting physicians before negotiating with private payers, considering some private payers adhere to coding guidelines that differ substantially from guidelines listed in the Correct Coding Initiative (CCI), the Medicare Carriers Manual and the local medical review policies (LMRP) of individual Part B carriers.
 
 
Brush Up on Modifiers. Incorrect modifier use tops the list of reasons why claims are denied.
 
The wrong modifier was used, or a modifier was not used when it should have been, or vice versa, says Arlene Morrow, CPC, a coding, reimbursement and compliance specialist in Tampa, Fla.
 
If the results of a diagnostic breast biopsy (19100*) lead your physician to perform a partial mastectomy (19160) later the same day, for example, Medicare guidelines published in CCI version 7.3 state that you should append modifier -58 (Staged or related procedure or service by the same physician during the postoperative period) to 19160.
 
You risk the claim being denied if modifier -58 is either not appended to 19160 or substituted with -59 (Distinct procedural service) or -51 (Multiple procedures).
 
Note: Modifier preference tends to be carrier-specific. Although some carriers may now prefer -58, others may prefer -59 or some other coding technique. If you have a private carrier, obtain its policy on use of these modifiers in writing.
Ensure Diagnosis Code Provides Medical Necessity. When the wrong diagnosis code is associated with a procedure, the carrier may deny the claim because medical necessity has not been demonstrated, Morrow says. Surgeons occasionally forget to update the diagnosis in the patient's chart, which can lead to denials if the ICD-9 code is not updated.
  
"We often do not show medical necessity clearly enough. We slap on a diagnosis when the patient comes in and it never gets changed," she says.
 
"A belly ache may be the reason the surgeon first saw the patient, but if the surgeon determines the patient has appendicitis and performs an appendectomy, the change from belly ache [i.e., 789.06] to appendicitis [i.e., 540.9] should be made when billing for the appendectomy."
 
The abdominal-pain sign or symptom may not provide medical necessity for the appendectomy, Morrow adds. Diagnosis coding is particularly scrutinized for vascular procedures, she notes.
 
Morrow recommends that vascular surgeons and their coders become familiar with LMRPs that include Medicare's indications for a given procedure, the covered diagnoses corresponding to those indications, and the documentation [...]