General Surgery Coding Alert

General surgeons should include a short section in their op notes that explains what they found, what they did and why they did it, says Lee Eisenberg, MD, an otolaryngologist in Englewood, N.J., and a member of CPTs executive committee. Although physicians have very good reasons for performing certain procedures, that information may not be as obvious to others, Eisenberg says, noting that office staff, carriers and other doctors all benefit if the op note contains a Findings section.

Physicians make a lot of intuitive decisions that others may not follow. A findings section would help othersyour own staff, reviewers at the carrier and even other physiciansunderstand your thinking and the procedure quickly, he says. The detailed information usually reported in the body of operative reports is not as important as what the surgeon found.

There is too much extraneous material in the body of the op note, Eisenberg says. Nobody cares what suture you used to tie off a blood vessel. Whats important is why you tied off the blood vessel.

Such a section need not be long: One or two paragraphs usually is enough to describe the findings that implicitly match what the otolaryngologist performed surgically, Eisenberg says.

Pathology Provides Important Information

The Findings section should describe what the pathology was at the time of surgery. If thats done appropriately, it will explain why the procedures performed were chosen, he says.

For example, when a surgeon abandons a laparoscopic appendectomy (44970) and converts to an open procedure (44950), the findings section might say: Findings: There was intense inflammation involving the cecum and terminal ileum, the appendix was obliterated. When attempt at mobilization was made, an abscess was discovered. For these reasons an open procedure followed. This short paragraph explains what the surgeon found (an abscess and intense inflammation making dissection and anatomic identification impossible). It notes what the surgeon did to correct the problem (the conversion to an open procedure) and, by adding three wordsfor these reasonssuccinctly explains why the laparoscopic approach was abandoned.

In another example, a surgeon performs a splenectomy, repair of small bowel injuries, and an end colostomy with formation of a mucus fistula for a GSW to the abdominal left upper quadrant.

A good findings section might read: There was extensive tissue destruction and clot. The injury to the spleen was in the hilum and there was widespread gross fecal contamination from the penetrating injury to the splenic flexure as well as two small bowel perforations. Because of the splenic hilum injury, the spleen had to be sacrificed and with the extensive colon trauma and gross contamination, a colostomy was elected. (This explains why the spleen was removedbecause removing the spleen changes immune function, there needs to be a good reason for doing it and why a colostomy was necessary). Two small bowel perforations were closed. Colon continuity will await a future procedure.

Findings Also Note Necessity

In these examples, the findings section briefly describes the medical necessity for the procedure performed. But it does more than that, Eisenberg says, noting that it can be useful:

In communicating with others, including office staff, other physicians and payers;
For medical-legal reasons; and
For reimbursement purposes.

A section at the beginning of an operative report that contains all the pertinent information about a procedure serves a number of purposes, Eisenberg says. It makes it easy for a reviewer to better understand what was performed should a payment issue arise. If the patient sees another surgeon in the future, it quickly and clearly describes what was done and why. And it may be useful if a legal issue arises.

Trayser M. Dunaway, MD, a general surgeon in Camden, S.C., agrees that such a section is a good idea. I often send letters to carriers to explain why I did more than usual that needs to be reimbursed at a higher rate. This technique will obviate the need for this letter. Even better, rather than going into detail buried in the body of the op note, such a section puts the material right at the top of the note, Dunaway says.

A findings section would be particularly helpful for reimbursement purposes, agrees Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C. It would help any carrier reviewing an op note to decide whether a particular procedure should be paid or not because it would explain why the surgeon had to perform a particular procedure. So instead of going back and forth with denials, appeals and letters, its all there, Callaway-Stradley says, adding that for coders, a section like this makes it easier to understand what the surgeon did and decide which code should be used.

Having a short explanation on hand of the whats and whys of the procedure also may be useful to the surgeon who performed the procedure, Eisenberg points out, by making it easier to review his or her own material.

At times, Eisenberg adds, it also may be useful to include the rationale that led to the decision to perform the procedure. Although a brief history also may be included, it should be part of the admission history and physical, he says.

For unusually long procedures, Dunaway recommends including the total amount of time spent performing the service. Say you take out a gallbladder, and it takes you three hours. Thats unusual circumstances. So in the findings section, you should mention that it took three hours, far more than normal, because of severe inflammation. That way, when you increase your fee by attaching modifier -22 (unusual procedural services) to the code (47563, laparoscopy, surgical; cholecystectomy with cholangiography), the carrier knows why because its right at the top of your op report.

Section Would Make Coding Coordination Easier

Surgeons often select their own surgery CPT codes via personalized fee tickets even when the operative reports are reviewed by a coder for CPT code accuracy before claim submission. On the hospital side, however, the ICD-9 codes reported for inpatient claims and the CPT codes used for outpatient claims are based entirely on the information contained in the op note because hospital coders dont have access to the surgeons fee tickets, says Laura Siniscalchi, RRS, CCS, CCS-P, educational coordinator at Beth Israel Deaconess Medical Center in Boston.

Because the post-op diagnosis and procedure performed information usually is minimal, the op report always must be reviewed completely to assign the appropriate codes, Siniscalchi says. Often, neither outpatient hospital coders nor physician coders have easy access to the patients history and physical, which may contain the rationale for a procedure that, in turn, might affect the correct choice of diagnosis code.

And even when doctors choose codes from code tickets, coding still should be compared against the operative report, says Barbara Cobuzzi, MBA, CPC, an independent coding and reimbursement specialist in Lakewood, N.J., because the most accurate portrayal of the procedures performed and why they were performed will make it easier to code more accurately and create a better basis for appeals. After all, Cobuzzi says, you usually dont pull the history and physicals when you appeal a denial either.