Being a surgery coder, I have almost coded most of the procedure codes in the surgery facility. To be frank, I have made lot of coding errors in surgery. Mistakes makes us to learn new things, but we should not repeat those mistakes again.
In coding as well, we should always learn from our coding errors and improve our coding knowledge. Today, I would just let us go through few of the common errors I have come across in surgery department. If you overcome these errors you will surely improve your coding skills.
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Open versus arthroscopic procedures
Medical coders sometimes overlook the documentation and choose the wrong procedure code. For surgery reports, coders need to properly read the operative note, in order to determine whether the procedure was open or arthroscopic.
Always compare the procedure header with the operative report. If the header and operative report has any discrepancies, do query the physician or provider. For example, if the procedure header mentions the open procedure and operative report document the use of scopes, than it will better to ask the provider to know the exact procedure performed.
Do not assume and code from procedure heading or body of the report, in case of any discrepancy. Medical coders should always read the entire operative report to find out the exact procedure performed.
Read also: When to use CPT code 79101 and 79005
Coding for lesion destruction per nerve, not the level
Pain management procedures are also little tricky to code. Coders make mistakes while coding radiofrequency ablation of lesions. For example, If the physician is performing radiofrequency ablation of lesions on three levels (for example, L2, L3 and L4), the coder would report three levels, not two levels as with facet joint injections.
Medical coders have to understand that they can code out for all three nerves, not just two levels. The coders should understand the documentation and code all the levels properly, missing any one of the levels will directly affect the procedure payment.
Coding the number of lesions incorrectly
Coding of lesions have also become a little confusing. The medical coders do not understand the code description and then choose the incorrect CPT code. There are CPT codes which has a range of number of lesion, for example second through or upto 14 lesion, which means it includes lesion from 2 (second) to 14.
For example, if there is a procedure of destruction of 14 premalignant lesion, medical coders can then report the primary CPT code, 17000 followed by secondary CPT code 17003 for each additional lesion up until the 14th lesion. For 15th or more lesion the coder should use CPT code 17004, rather than using CPTs 17000 and 17003.
Read also: Coding guide for using Ultrasound Pelvis and Endovaginal CPT codes
Reporting both arthroscopic and open techniques for one procedure
When a procedure begins arthroscopically and then convert to an open procedure, then the coder should only report the open procedure. For example, if the physician performs a rotator cuff repair arthroscopically and due to some reason converts the arthroscopic procedure to open procedure, then as per the guideline we should only report the open procedure. When only a single or same procedure is converted from arthroscopic to open, then only we have to report open procedure code.
When both procedures are performed differently and done separately, in such case both (arthroscopic and open) procedure should be reported separately. Do not misinterpret the coding guidelines and follow the rules properly.
Wrong Procedure code for debridement of ACL
When there are no more specific procedure codes, then medical coders needs to report or use unlisted codes. For example, for debridement of cartilage, we have to report CPT code 29877, but for arthroscopic debridement of ACL ligament has no specific CPT code. Hence, for such procedure unlisted CPT code 29999 should be reported.
In the same way medical coders use CPT 29828 to code arthroscopic biceps tenotomy, rather than using unlisted code 29999 as appropriate.
Read also: Top common ICD 10 coding Errors by Medical coders
Failing to code for different polyp removal techniques
For GI procedures, there are separate CPT codes for each different technique for removal of polyp. For example, the use of cold biopsy, a hot biopsy or a snare biopsy to remove three different polyps. When all these techniques are used together on different polyps, we have to report each technique separately.
Number of polyps does not matter here. For example, if a hot biopsy is used to remove two polyps and a cold biopsy is used to remove one polyp, then both the techniques should be coded separately.
You can code different techniques on different polyps, as long as they are used to remove the polyps.