Wiki Compliance question

[kparkhurst]

I do the coding for our billing service's anesthesia client. Is it essential from a compliance/audit standpoint for the anesthesia codes to match the surgeon's code? (we do not receive a copy of the op report). Example - procedure listed on billing sheet sent from the anesthesia group states "Endoscopic carpal tunnel, possible open". Even though the base units for both are the same, can you code this an endoscopic and not question it? The anesthesia group is telling us that it is OK to code in this manor, however, it makes me uncomfortable. Any guidance would be appreciated! (And if anyone has any documentation for support, that would be helpful too!)

 

[dav4code]

If the possible cpt codes crosswalk the same ASA code, there isn't a problem, but if an alternate is possible with higher base units, just make sure the documentation supports choosing it; if you must, have the surgeons office fax the op note to you.

"If it ain't documented, it can't be coded"

 

[cmacpc]

The beginning of the month AAPC had a webinar on anesthesia and the presenter mentioned some of the coding "Pitfalls" one of them being "Coding form a charge ticket instead of the actual medical record".

 

[kparkhurst]

Thanks for the info - I will be watching it tomorrow!!!