Ok, I know I am not a dummy but can someone please help me out- I am having a terrible time explaining documentation issues and requirements to my physicians.
Example one, I had a surgeon-we'll say DR. B- that wanted to bill out for mod 80 on a claim bc she was there and assisted with the surgery. So, I get the OP note and I only see one physician-DR. A listed. I kindly ask that DR. B be documented in the OP note as 'Assistant Surgeon' with a sentence explaining why it was necessary to assist... That opened a whole can of worms that said that wasn't necessary and that I should check my coding companion resources as mod 80 is allowed for a certain surgery that was performed.
Example Two, Dr. A is listed as assistant surgeon and that's it. There is no sentence that states why they need an assistant surgeon to help- according to CMS and BS, it's my understanding that "a hospital may require an assistant to be present at every surgery because of malpractice liability" so since this particular OP note didn't correctly document CMS/BS guidelines, I assumed DR. A wasn't really involved. Wrong answer to assume.
I sent out an email that stated these requirements per BS/CMS. They wanted to know when that rule changed? I thought it's always been known to provide documentation and especially when a modifier is being appended to any claim? Am I being silly to ask them to follow what needs to be documented? I've heard too many horror stories about coders doing something just bc the physician said to do it and they've paid the ultimate price- losing their credentials plus paying back fines and being bannded as a fraudulent coder. I'm just trying to protect myself and my physicians as well.
Wellmark does not require an operative report to be submitted with the claim. However, if the claim is denied and a review is requested, an operative report must be attached to the Provider Inquiry form.
As evidence of medical necessity for the services, the surgeon is required to note the following in the body of the operative report:
• The specific nature of the assistant's services
• The reason the assistant's services were required
This is required even if the surgery is listed by CMS as appropriate for an assistant surgeon. Listing the assistant surgeon's name in the heading of the operative report does not validate medical necessity.
Example one, I had a surgeon-we'll say DR. B- that wanted to bill out for mod 80 on a claim bc she was there and assisted with the surgery. So, I get the OP note and I only see one physician-DR. A listed. I kindly ask that DR. B be documented in the OP note as 'Assistant Surgeon' with a sentence explaining why it was necessary to assist... That opened a whole can of worms that said that wasn't necessary and that I should check my coding companion resources as mod 80 is allowed for a certain surgery that was performed.
Example Two, Dr. A is listed as assistant surgeon and that's it. There is no sentence that states why they need an assistant surgeon to help- according to CMS and BS, it's my understanding that "a hospital may require an assistant to be present at every surgery because of malpractice liability" so since this particular OP note didn't correctly document CMS/BS guidelines, I assumed DR. A wasn't really involved. Wrong answer to assume.
I sent out an email that stated these requirements per BS/CMS. They wanted to know when that rule changed? I thought it's always been known to provide documentation and especially when a modifier is being appended to any claim? Am I being silly to ask them to follow what needs to be documented? I've heard too many horror stories about coders doing something just bc the physician said to do it and they've paid the ultimate price- losing their credentials plus paying back fines and being bannded as a fraudulent coder. I'm just trying to protect myself and my physicians as well.
Wellmark does not require an operative report to be submitted with the claim. However, if the claim is denied and a review is requested, an operative report must be attached to the Provider Inquiry form.
As evidence of medical necessity for the services, the surgeon is required to note the following in the body of the operative report:
• The specific nature of the assistant's services
• The reason the assistant's services were required
This is required even if the surgery is listed by CMS as appropriate for an assistant surgeon. Listing the assistant surgeon's name in the heading of the operative report does not validate medical necessity.