Wiki A little advice

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KellyLR

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I need some help. I recently started coding for a practice involved in orthopaedics for our coding and billing service. Most of the providers are fantastic with their documentation. However, ;) there are a couple of docs who dictate ops and after they are transcribed, they include everything that they do in surgery in detail, but they never say what procedure they performed. I am having a tough time with the terminology and discerning what procedure they actually did. I try to compare the op reports with the other surgeons and that helps, but what would one of you do in this situation? Politely ask the surgeon to dictate in their notes the type of surgery he did. I'm at a loss to figure out how the other coder before me handled this being that this practice is so new to our business and we don't get the liberty to review older records right now. I feel uncomfortable about reading the report and extracting all the elements and then deciding what procedure the doc performed. I have been burning the midnight juice to educate myself quickly concerning Musculoskeletal and its mechanical properties but i never thought about anesthesia, hip traction for two hours then perform a procedure/revision/reconstruction but not total hip replacement or implant for one side and then do the same for the other! This one doc describes how he removes burrs and stuff from the acetabular. This is kicking my butt!

Please help, anything would be appreciate in how to approach this matter.
 
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ive been doing ortho and evrything else under the sun for 14 years and i found that the coding procedure book is the bible when its come to what each procedure curtails.. another thing i do to this day is when come across a complicated op note is to print it out and circle each incision that was performed and that will simplified things a little....for each incision is usually one cpt(not always) and alot of the things that is described during each incision is parts of one procedure or cpt code..again not always but most of the time.....hope this help a little! only time will give you the experience and confidence so hang in there and enjoy the ride!
 
Thanks!

I appreciate the input and encouragement. I do use a coder's reference book but to be honest it is a little outdated. I went to AAOS and purchased a GSD that is published by them. I figured it couldn't hurt to have more reference resources and I plan to have the office update their cpt desk reference book this coming week. Hopefully I can build my skill and confidence level with your suggestions. I'm not afraid to take on a challenge and the office here knew I meant that and I am sure that is why they took on this practice. My fearlessness gets me into doo doo sometimes! We are still in the initial staging process of setting them up with us so I have maybe two weeks to get over there and snoop through their records because I was also assigned to help do a light audit this next week. Found this out about 30 minutes ago. (I realize it's Sunday) We plan to audit 100 records from the past six months for each provider and I'm excited to see how well they do for documentation. From reviewing their reports, they seem to have very good doc skills, I just need to get acclimated!

When you mentioned to make note of each incision, that I do and it is rather difficult for me right now to figure out what is included in the CPT code and not to unbundle services and decide when it is "separate procedure." But I'm sure once I get additional ammo in my hand, and train myself on what to watch for and abstract from the report, I'll get it.

Thank you so much:D
 
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