Wiki Phrase Enough for Bilateral?

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dballard2004

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We are having a dispute in our office about coding for a bilateral mastectomy. The surgeon's op note clearly outlines in detail how the procedure was performed on the left breast. Then, when it comes to the right breast, the note just says, "Same procedure was completed on the contralateral side." We see this type of documentation all the time when it comes to bilateral mastectomies, but we are getting pushback from another coder stating that the phrase is not sufficient documentation to warrant coding this bilateral. It seems to me to be more work for the provider to basically have to state the same thing over again if nothing changed from one side to the other.

Any thoughts? Can anyone point me to specific requirements that state that that phrase is not sufficient? Thanks.
 
I could see it both ways. From a staff coder side, I can see why someone would just take that and code it. From a payer side, I can see why it would be unacceptable and denied. That is not enough information. While they may not have to completely repeat everything, or make a separate op note, it might be better to improve the documentation to be more descriptive and elaborate more. I think this is a documentation improvement opportunity. I don't know that you will find a specific guideline with exact wording of how it MUST be. A hospital or facility may have more restricitive policies internally. If it went to med review or audit, it would probably not be acceptable. If you have a CDI team or compliance committee, this seems like a good topic if it is widespread in the group.

Some payers may have wording in a bilateral surgery or bilateral coding policy document, like this example: https://www.bluecrossmn.com/sites/d...ntional-Procedure-002-Bilateral-Procedure.pdf "Documentation Submission Documentation/operative report must identify and describe the procedures performed." So, again, if going to a review or audit, it *could* be denied by that sentence.

Medicare/MAC language examples: https://med.noridianmedicare.com/we...ocumentation-guidelines-for-medicare-services https://med.noridianmedicare.com/web/jeb/topics/documentation-requirements/surgery https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00144726

"Reviewers determine that claims have insufficient documentation errors when the medical documentation submitted is inadequate to support payment for the services billed (that is, the reviewer could not conclude that some of the allowed services were actually provided, were provided at the level billed, or were medically necessary)"

This is an old thread but may have a couple links that still work: https://www.aapc.com/discuss/threads/documentation-requirements-for-bilateral-procedures.149088/

https://www.aapc.com/blog/49512-dissect-an-operative-report/ " If the procedure was performed bilaterally, then both sides must be documented here in some fashion, even if it is already stated as such in the Heading."
 
Hello D Ballard,
Contralateral means relating to or denoting the side of the body opposite to that on which a particular structure or condition occurs. So this means BOTH side or both breasts/mammary gland treated since provider said did same procedure on contralateral side. Also I noticed in ICD10 manual dx N60, N61.2 N63 ,C50, C57, D47 both have specific dx codes for right and left designation of laterality relate to mammary glands.
I hope this info helps too.
Lady T
 
I've noticed over the years that even though a procedure might be performed bilaterally, that there are slight differences in the procedures which makes them unique to that patient. If your provider wants to use a statement stating that the same procedure was performed on the contralateral side, they could use that statement with some of the slight differences during the procedure. I've worked with surgeons that replace knees. Most dictate a note specific to that patient and how the knee was prepped. There are differences in this process. One surgeon I worked with had a template. He just filled in a few blanks with the size of the prosthetic, but other than that, every note was exactly the same. If there was a postoperative complication, his note would be worthless. If your doctor is going to use this short-cut, at least include a small note that shows the difference between one side and the other.
 
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