Ob-Gyn Coding Alert

Save these on-the-go documentation tips to ward against big mistakes If you-re relying on the title of a hysterectomy report to choose the most appropriate code, you could be setting yourself up for costly denials. Read your note carefully and highlight what the physician actually did. Can't find this information? You may have to approach the physician. To save yourself the trouble, compare these two hysterectomy operative reports and learn what makes a good and bad note -- and what to do about it. Examine Example of Poor Documentation Preoperative diagnosis: Uterovaginal prolapse
Postoperative diagnosis: Uterovaginal prolapse
Operation: Hysterectomy; anterior and posterior repair

Procedure: The patient was placed in a lithotomy position, and the perineum and vagina were prepped in the usual sterile manner. A tenaculum was placed on the lip of the cervix, and the cul-de-sac was entered. The bladder was pushed off the cervix and the lower uterine segment and the anterior cul-de-sac was entered. The uterosacral and cardinal ligaments and the uterine vessels were clamped, cut and ligated. The fundus of the uterus was inverted, and adnexal structures were clamped, cut and tied. The peritoneum was closed with a purse-string suture. The cystocele was repaired. The procedure was concluded, and vaginal packing was put into the vagina. The patient tolerated the procedure and was sent to recovery in good condition.- Why This Example Is a Bad Op Note What you don't know: You cannot determine whether this is a vaginal hysterectomy or an abdominal. "It looks as if the physician left a whole piece of the operation unstated," says Cheryl Ortenzi, CPC, billing and compliance manager at BUOB/Gyn in Boston. Moreover, "you only have minimal documentation of the repair" but you don't know if it's an anterior and posterior repair, says Marvel Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting in Denver. "You also don't know whether he removed any ovaries or tubes. You have several potential codes in the 572xx code range, and without the detail you can't compliantly select a code." In other words, "you have to have your doctor document this information so that the documentation supports what you bill," says Karen Green, CPC-H, OGS, coding specialist at Eau Claire Women's Care in Wisconsin. Action steps: You should "review any addendum reports," Hammer says. If you still have questions, get clarification from the physician immediately. "Our physicians know that they can maximize their reimbursement for the work they did if they have good documentation," Ortenzi says. They understand if "we have to go to the physician directly for notes that do not make sense or have missing words." Also, ask an experienced coder to explain what's generally done during a hysterectomy so you-ll learn more [...]