Wiki Size of Complex Closure documentation WITHIN the body of the note

[Lubovic]

Recently UHC has been denying Repair-Complex closure (13121-13122) charges because they say "the size is not documented within the body of the note." My MDs have always documented the final size at the top in the Procedures sections.

"OPERATIONS AND PROCEDURES PERFORMED:
1. Wide local excision of right upper arm melanoma (1.5 cm margins) [ Excision area 6 cm wide, 9 cm long, this includes the lesion and the margins]
2. Complex wound closure (3 layers)
3. ..."

Does anyone have any documentation to prove or disprove this requirement?

I was not able to find any documentation in UHC's policies or CMS policies that states it MUST be within the body of the note. My rationale is that my doctors do not stop to measure as they cut. They excise and once they are done document the final size since it is not always what was anticipated at the start.
I'm really frustrated with UHC for denying these just because they are on a different line of the report. I refuse to let them bully us.
Any appeal advice is appreciated.

 

[antoniamay]

So this is more of a coding basic, so way back in the very beginning, you may remember we learned that the procedure note or operative report contains 4 sections - The Header, indications for surgery, the detail or body of the procedure, and the findings. As a coder, we should not be selecting a procedure code from information in the header, it has to be documented in the body of the report, this applies to codes and modifiers, when I audit I deny things for this reason all the time. Keep in mind that major payers often use 3rd party vendors to audit. UHC does this a lot so other payers may be paying because they aren't reviewing your notes.

Therefore in order to verify the correct CPT code is being selected for the claim you will need to be documenting it in the body of the note.

CPT says "When coding for wound repair (closure), you must search the clinical documentation (body of the report) to determine three things:

1. The complexity of the repair (simple, intermediate, or complex)
2. The anatomic location of the wounds closed
3. The length, in centimeters, of the wound closed"

I would talk to your physician and just make sure he is also documenting all the above in the body of the note to reduce denials or move that section down to the body of the note to detail it, I am not sure what system you all use for charting. Hope this helps!