Wiki Surgery Coding

[terry4162]

Good Afternoon - I just wanted to check some coding rules for which I am starting to get confused on. Say the physician decides to do a thyroglossal duct cyst excision as the patient has a mass and ultrasound confirm most likely a thyroglossal duct cyst or cystic structure. They obtain prior authorization for 60280. Now op-note states excision of neck mass surgery documents a mass abutting and adhered to the thyroid cartilage lamina which is excised but no hyoid bone removal as there is no tract and physician states appears to be dermoid cyst. Do you still code for the 60280....if not coded this way the insurance UHC will deny for no prior authorization for another code. I had another one like this were the physician got authorization for a parotid mass excision, but path came back as a lymph node...what do you code for??? I could use some advice so I quit second guessing myself and can give my coders the correct answer you get a little foggy on rules when you've been coding since 1990. Thanks for any assistance in this matter.

 

[b.cobuzzi]

When the doctor performs a different surgery than was pre-certed because he finds a different situation once he gets into the patient, he should immediately notify the pre-cert department to call the insurance to AMEND the pre-cert with what was actually found and performed. Most if not all insurance companies will amend the pre-cert so that you can properly bill and code the surgery.

Since this one was not amended right away, you should have your pre-cert department call and ask for special dispensation and beg them to amend the pre-cert retroactively in order for the surgery to be coded and be billed correctly.

You must code and bill the surgery per the documentation, not per the pre-cert. If it is denied, appeal explaining the situation and how the ball was dropped in the amendment of the pre-cert and provide the documentation for correct processing of the surgery. Explain that the surgery must be coded per the documentation and what was actually performed. The surgeon found a totally different situation once he got inside the patient’s neck and performed the appropriate surgery while you coded it appropriately.

Good luck and hopefully you can train your physicians to give feedback to your pre-cert department in the future for amendments.