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General Surgery Coding Alert

Office Protocols Ensure Proper Billing Procedures

Published on Sat Dec 01, 2001

Surgery practices require protocols that guide the entire coding, billing and reimbursement process. Such protocols can prevent coding errors and provide strategies for dealing with reimbursement problems. Many protocols can optimize efficiency and stay within correct coding parameters. Some of the more important protocols follow:
 
1. Review codes and modifiers and revise when necessary. Although surgeons are ultimately responsible for coding decisions, coders and other billing staff may be asked to modify or even select CPT and ICD-9 codes. A member of the coding or billing staff should be responsible for comparing the surgeon's documentation to the information on the form when claims are filed. This helps to ensure that all services being claimed are documented, all bundling guidelines have been followed, any appropriate modifiers have been used and the procedures and services being claimed are listed properly.
 
Example: The surgeon removes a Medicare patient's appendix and lists the following procedures: 49000 (exploratory laparotomy, exploratory celiotomy with or without biopsy[s] [separate procedure]), 44005 (enterolysis [freeing of intestinal adhesions] [separate procedure]) and 44950 (appendectomy). Although the surgeon has assigned these codes, the coder reviews the claim and determines that the laparotomy and the lysis of adhesions are bundled with the appendectomy and should not be billed separately.
 
Example: Two weeks later, while in the appendectomy's 90-day global period, the patient has a fever and shows signs of infection. The surgeon takes the patient back to the operating room and reopens the abdomen to deal with the infection. On the form, the surgeon has billed 49002 (reopening of recent laparotomy) without a modifier. The individual responsible for checking and revising codes adds modifier -78 (return to the operating room for a related procedure during the postoperative period), without which the claim likely would be denied.
 
2. Ask the physician for an addendum if documentation is inadequate. Coding and billing personnel who check codes and modifiers for accuracy must ensure that the surgeon's documentation supports the procedures being billed, says Arlene Morrow, CPC, CCC, a general surgery coding and compliance specialist in Tampa, Fla. If the documentation is vague or incomplete, the surgeon must complete or revise the patient's chart as necessary, Morrow adds, noting that the conditions for adding or revising documentation must be followed.
 
Example: The surgeon performs an examination and determines that an established patient has a bowel obstruction. The surgeon bills 99214 (established patient office visit) for the E/M service provided. Upon review of the documentation, however, the coder discovers that the documentation does not support such a high-level visit. In this situation, the individual who reviewed the claim (or another coding or billing staff member) should question the surgeon about the visit, Morrow says. If a Level Four visit was performed but not documented, the surgeon should be asked to provide an addendum. A surgeon writing an addendum must provide the addendum in a timely manner, clearly indicate the additional submission is an addendum and date the addendum on the day it is written (not on the day of the procedure or when the original documentation was dictated).
 
3. Obtain carrier policies in writing. Third-party payers often have reporting requirements that differ significantly from those of Medicare and from each other. To code procedures differently depending on the payer, however, the policies of the carriers should be obtained in writing and coding and billing staff should be instructed on how to access these written policies when required, says Susan Callaway, CPC, CCS-P, a coding and reimbursement specialist and educator in North Augusta, S.C.
 
Example: The surgeon uses a tissue adhesive (Dermabond) to close a wound on the patient's torso. Medicare and some private payers require surgeons to report HCPCS G0168 for this service; however, other carriers follow CPT instructions, which state that the appropriate simple repair code (12001-12021) should be used. In this case, both the CPT instructions and, if available, the carrier's policy should be filed for future reference.
 
Note: Billing the same service to obtain or to boost payment is not permitted and would be considered fraud.
 
4. Develop a strategy for handling coding errors discovered after the claim has been sent. "I get asked questions about this all the time at my seminars," Callaway says, recommending that a member of the surgeon's coding or billing staff in this situation submit a corrected claim if the original claim has not already been processed (the carrier may even be able to adjust the claim even if it has already been processed in some cases) and write a letter or otherwise get in touch with the carrier (having a reliable contact on the payer side can be very helpful).
 
Example: The surgeon performed an exploratory laparotomy and an appendectomy, but the documentation is confusing. The coder assumes that the exploratory laparotomy was done at a different session on the same day as the appendectomy and bills 44950 and 49000 with modifier -59 (distinct procedural service). Subsequently, the coder learns that both procedures, which are normally bundled, were performed during the same session. The coder calls the carrier to inform them of the error and is instructed to submit a new claim.

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