Wiki Am I Crazy?

[dballard2004]

I have a coder telling me that when it comes to adjacent tissue transfer that if the size of the defect is not documented, you select the code based on the lowest level.

For example.... tissue transfer of the forehead. Note states the provider did the procedure, but the sq cms required are not documented. The coder says that in this case you would "code the lowest level of the service" which is 14040.
I say that the measurements are required for code selection since this is outlined in the code description and if the measurements are not documented, you can't code the service. The coder says that this thinking (going with the lowest level) is the "rule of thumb" for these procedures. Am I missing something here? Am I crazy?????

 

[amyjph]

You can't report any of those that have the size in the description without the measurement being documented. (Like you stated).
There must be a query and op report sent back.

Goodness gracious sakes alive, why in heck would you just down code it anyway even if you could?
Not the rule of thumb, sounds like a made up "rule"?

 

[dballard2004]

You can't report any of those that have the size in the description without the measurement being documented. (Like you stated).
There must be a query and op report sent back.

Goodness gracious sakes alive, why in heck would you just down code it anyway even if you could?
Not the rule of thumb, sounds like a made up "rule"?

My thoughts exactly! I was just making sure there wasn't a rule out there that I wasn't aware of!

 

[Tcoder4]

Coding to the lowest level is common in facilities where the turnaround is short, or the providers are known to not answer queries. It depends on the facility policy. Ideally there would be a query.

 

[dballard2004]

Coding to the lowest level is common in facilities where the turnaround is short, or the providers are known to not answer queries. It depends on the facility policy. Ideally there would be a query.

Interesting! Then how would you appeal if the claim denied or worse, how would you defend the coding in an audit?

 

[Tcoder4]

Interesting! Then how would you appeal if the claim denied or worse, how would you defend the coding in an audit?

I'm looking through my notes, and it appears to be a site policy in most cases. I will update if I come across anything in CPT Assistant or Coding Clinic.

 

[amyjph]

I have heard people say it before with debridement, if the provider doesn't document the depth and measurements, and they don't answer the person coded the lowest option.

 

[Kristen Bensel]

That seems risky to code a service that isn't fully supported in the documentation.

I was taught that if a provider does not get all of the required documentation for a specific procedure in the original documentation, then it was not to be coded. how can it be coded if it isn't fully supported? We weren't even supposed to reach out to the provider for them to possibly addend with the missing information. as it could be seen as trying to seek more revenue than what is in the original documentation. We coded what we could for the visit, and then it was used as an educational tool for the provider for the next time they did a procedure. I can tell you that with that mind set the providers were very diligent about making sure they were documenting all of the necessary elements.

I will say though that if you do reach out to a provider for them to clarify that necessary information and they don't respond? That is a response in itself. I wouldn't code it if it isn't fully supported.

 

[amroach68]

A little OT but we do this all the time with "unspecified" codes for Dx like CKD. If the provider documents CKD 3 and also documents the GFR, instead of querying them to see if they clinically deem it to be CKD stage 3a or stage 3b, etc, we are instructed to automatically change the code to "CKD 3 unspecified". To me, this is not the best thing to do since the name of the game is always coding to the highest level of specificity. And sure, if the provider doesn't respond to a query ok, play it safe and use unspecified, but we're not even being asked to query.

 

[toria11]

Same with bladder tumors. The AAPC course teaches coders to code for the lowest level available if size is not given in the OP note (and a query can't be made).

 

[kdlberg]

A little OT but we do this all the time with "unspecified" codes for Dx like CKD. If the provider documents CKD 3 and also documents the GFR, instead of querying them to see if they clinically deem it to be CKD stage 3a or stage 3b, etc, we are instructed to automatically change the code to "CKD 3 unspecified". To me, this is not the best thing to do since the name of the game is always coding to the highest level of specificity. And sure, if the provider doesn't respond to a query ok, play it safe and use unspecified, but we're not even being asked to query.

Is it possible the person doesn't know that there are different codes for 3a and 3b? I'm only saying this because I've been seeing things in another coder message board (not AAPC!) where the person supervising the coders isn't a coder. Or maybe the doctors don't know we (coders) can't look at the GFR and say if it's 3a or 3b. I've been fighting that battle over obesity--the provider says "but the BMI is right there!" and I have to explain that obesity is a medical condition so they have to diagnosis it.