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Part B Insider (Multispecialty) Coding Alert

SURGERY:

How to Read a Colon Surgery Report

Published on Tue Oct 21, 2003

Decipher terminology to come up with correct coding for colon procedures

When it comes to colon procedures, many coders end up confused by oceans of verbiage that doesn't bear any resemblance to any code descriptors they know. And meanwhile, reimbursement is going out the window.

Reading an operative report for a colon resection or other operation may be confusing for coders. "It's amazing how [surgeons] don't take their CPT books into the operating room and do what's described by the book," says Marcella Bucknam, HIM Program Coordinator at Clarkson College in Omaha, Neb. Surgeons' notes may be up to four pages of descriptive notes, making it hard to understand what happened.

Surgeons sometimes don't use the same terminology as the Common Procedural Terminology book does when it describes common colon procedures. Instead of saying she did a "partial colectomy with coloproc-tostomy (low pelvic anastomosis)," the surgeon may describe the procedure in detail. Similarly, the surgeon may describe attaching the remainder of the patient's colon to an area so many centimeters from the anus, Bucknam says. To translate that into CPT Code 44145 (Colectomy ...) "requires a great deal of anatomical understanding on the part of the coder," she says.

Surgeons sometimes use all-purpose terminology, such as "hemicolectomy," which can mean a left or right sigmoid colectomy, says M. Trayser Dunaway, a general surgeon in Camden, SC. "There are so many different terms that it causes confusion."

This confusion especially makes it difficult to ascertain what services the surgeon provided that should be coded separately, or what procedures the surgeon didn't perform that are normally considered part of the code you're billing, Bucknam says.

But there are a few things you can do to clear things up:

  • Take it from the top. "One of the most valuable aspects of reading from a note is to start at the top where the physician lists all the things" he or she did, Bucknam says. You may be able to find all the information you need there, before you dig all the way through the note and "get bogged down in lots of information that doesn't actually change your coding." It's always important to read the note all the way through, however.

  • Draw a picture. "Consider having the surgeon doing a little sketch; just tell the surgeon to x out the part that he removed," Dunaway says. He uses a form that includes his drawing of the colon, which he and other surgeons can use to mark where they operated.

  • Take in the highlights. Print out an extra copy of the report and highlight phrases that appear to be important. Look for information such as whether the surgeon performed an anastomosis, Hartmann procedure or colostomy. This will help you "find the code that most closely describes what the surgeon did."

     

     

     

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