Otolaryngology Coding Alert

Otolaryngologists 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 the CPTs executive committee. Although physicians have very good reasons for performing the procedures they do, 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 such 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 otolaryngologist 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 does not need to be long. One or two paragraphs usually are 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 an otolaryngologist inserts tympanostomy tubes (6943x, tympanostomy requiring insertion of ventilating tube), the findings section might say: Findings: There was thick fluid in both middle ears. The right tympanic membrane was adherent to the promontory. For these reasons t tubes were placed.

This short paragraph explains what the otolaryngologist found (thick fluid in both middle ears, right tympanic membrane adherent to the promontory). It notes what the otolaryngologist did to correct the problem (the placement of tubes) and, by adding three wordsfor these reasonssuccinctly explains why the tubes were placed.

In another example, an otolaryngologist performed a tympanoplasty with mastoidectomy without ossicular chain reconstruction (69635, tympanoplasty with antrotomy or mastoidotomy [including canalplasty, atticotomy, middle ear surgery, and/or tympanic membrane repair]; without ossicular chain reconstruction). A good findings section might read: There was a total central perforation. In the mastoid a cholesteatoma was found extending into the middle ear and involving the incus and stapes including the footplate. The facial nerve was covered. The IS joint was eroded. The footplate was mobile. The chorda tympani was involved with the cholesteatoma and had to be sacrificed. (This explains why the chorda tympani was removedbecause removing the chorda tympani changes taste sensations, there needs to be a good reason for doing it.) A facial recess was completed as part of the mastoidectomy. An ossicular reconstruction was not done at the time because the cholesteatoma could not be removed from the footplate and will await a second look.

Findings Also Note Necessity

In both 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 otolaryngologist in the future, it quickly and clearly describes what was done and why. And it may be useful if a legal issue arises.

A Findings section would be particularly helpful for reimbursement purposes, agrees Beth Sutton, a coding and reimbursement specialist in the office of Paul Antalik, MD, in Pittsburgh, Pa. For anyone who is coding, a section like this provides more information and makes it easier to understand what the surgeon did and to make a decision as to what code should be used, Sutton adds.

Having a short explanation on hand of the whats and whys of the procedure also may be useful to the otolaryngologist 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, Eisenberg recommends including the total amount of time spent performing the service. Say you take out a cystic hygroma (228.1), and it takes you six hours. Thats unusual circumstances. So in the Findings section, you should mention that it took six hours, far more than normal. That way, when you increase your fee by attaching modifier -22 (unusual procedural services) to the code (3855x, excision of cystic hygroma, axillary or cervical), 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 procedure 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 don't 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 must always be reviewed completely in order 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.