Neurosurgery Coding Alert

If the surgeon does not circle a diagnosis, it may be up to you to find one Don't let an incomplete superbill damage your chances of submitting an accurate claim. If the neurosurgeon in your office fails to indicate the ICD-9 code for the condition that he treated, you should read through his documentation to find which diagnoses you should report. Open the Notes When You Have to -- and Even When You Don-t Suppose your neurosurgeon hands you a superbill with the procedures circled and the diagnosis left blank. You could ask the physician which diagnosis to report, or you could examine the documentation yourself. -If your office has a policy that includes -coding by abstraction- by certified/qualified coders, then submitting charges based on what is supported (documented) in the note is appropriate,- says Ellie Sclocchini, CPC, consultant with Physician Reimbursement and Compliance Specialists in Mullica Hill, N.J. -The physician should be signing off on these charges as part of your internal policy.- Some practices choose to review the documentation and compare it against any diagnoses recorded on the superbill, even when they aren't required to. This ensures that the documentation matches the code selection every time. -I know it is more work, but I always check the superbill against the chart note, and I usually bill the problems listed in the note over the superbill,- says Louise Glynn, office manager at Riverbend Medicine in Fuquay-Varina, N.C. -We are on an electronic medical record (EMR) system, so it is easier than reviewing paper charts, because with EMR, the physician selects the code and the note is very specific.- When in Doubt, Confirm With the Physician If you are new at coding diagnoses from the physician's notes, you should double-check your code selections with the neurosurgeons until you feel comfortable that you are choosing the right codes. This may depend on the amount of detail that your physicians document in their notes or the variety of conditions that your practice evaluates. Tip: Make sure your office creates a policy in writing that spells out what you should do when you encounter a superbill with no diagnosis listed. Some physicians prefer that you ask them for information, while most others rely on their coders to select an accurate code. Check the Notes for Clues Consider this example of a situation in which the coder must fill in the gap when the neurosurgeon has not written a diagnosis on the patient's superbill. Example 1: The neurosurgeon's superbill shows a level-three consult with a patient wearing a lumbar orthosis (L0625). It also shows a date of injury of three days prior to the date of service and is missing the diagnosis code. First [...]