THE MAGIC OF CODING OPERATIVE REPORTS-By Susan …



THE MAGIC OF CODING OPERATIVE REPORTS-By Susan Garrison

Retyped article from Nancy Maguire’s Coding and Billing Expert

September/October 2002

Well, maybe we won’t pull a rabbit out of the hat, but we certainly can look for the tricks and tips to code from operative reports appropriately. We are going to walk through the techniques I use when coding (or auditing) operative reports. This step-by-step guide will hopefully help you make sure your coding is optimal and accurate.

Using the sample report in Figure 1 (below), let’s start with the steps for coding from an operative report:

Figure 1. Sample operative report

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Step # 1

Underline information important to coding. (See figure 2.)

Figure 2. Operative report with underlined action items.

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Step # 2

Code all underlined notes and ask yourself these five questions when coding an operative report. (See figure 3.)

Figure 3. Operative report with coded and underlined action items.

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1. What body system is involved? Ask yourself this because the CPT is broken down by body system (e.g., Integumentary, musculoskeletal, etc)

Answer = Digestive (now, we know we need to look in the digestive section of CPT beginning with the 4xxxx range).

2. What body part? We ask this because the CPT is, in large part, further divided within the body system by specific body site (e.g., nose, sinuses, larynx)

Answer = colon (now, we know we need to look in the rectal area of CPT Digestive beginning with the 45xxx range).

3. What approach was used? Again, the CPT drives man codes by how the surgeon approached the area (e.g., knee surgeries performed arthroscopically are coded differently from knee surgeries performed in an open manner.)

Answer = endoscopic (now, we know we need to go to the endoscopy section of CPT Digestive Rectum beginning with the 453xx range)…and since it’s to the cecum, that starts with 4537x range)

4. What is the root operation? This is where we start digging into the detailed code. If the root surgery is an excision or a biopsy or whatever it may be, the specific code varies. At this point you should pretty much be at the CPT code you are going to use.

Answer = diagnostic exam and snare polypectomy…to code 45378 and 45385.

5. What are the modifying factors? This would include such items as if it’s a staged procedure, a repeat procedure or one of those many questions that may drive the addition of a modifier.

Answer = none outstanding in operative report that would add another code or modifier.

You may notice here that I have asked you to code everything you underlined. This is because when you are first learning how to code an operative report, I want you looking for all the action items and in the next step we’ll look to see what should be bundled and what shouldn’t. I don’t expect that you would go through all of these steps when you are an expert surgery coder; however, it’s important to understand all aspects of the operative report whether new or old to coding if you are going to be explaining your coding (say, during an audit education session).

Step # 3

Check for bundling issues that would occur due to CCI (Correct Coding Initiative) edits or separate procedure designations, etc. Bundle those codes that are not appropriately coded separately or apply an appropriate modifier to justify your coding.

Title vs. Text. Reimbursement is often lost due to coding from the title of the operative report. Surgeons often dictate a title for the major procedure only, but when the text of the operative report is reviewed, additional procedures may be coded. Also, increased complexity and other modifying factors may be discovered within the text of the operative note and not mentioned within the title.

Okay, our final step

Bundling issues. Are there any bundling issues in this coding? We have two CPT codes, CPT 45378 and CPT 45385. If you look at these two codes, you will notice that CPT 45378 is a separate procedure and therefore, it may not be coded at the same operative session as a more major therapeutic procedure of the same body site (the CPT 45385) and we lose the CPT 45378 leaving us with CPT 45385 as the only code on this operative report.

As you can see for illustrative purposes, I’ve used a very simple operative report but these same steps and guidelines are used most effectively with the most complicated operative report. All you are doing is taking the report step by step and coding each phase, then wrapping it up at the end by removing the coding that is incidental to the main surgeries.

I’ve found that in teaching CPT coding of surgeries, this proves a most useful exercise in really getting the process down in your mind.

Susan Garrison, CPC, CPC-H, CPAR, CCS-P, is the most recent past-president of the American Academy of Professional Coders. She has spent the last twelve years consulting with physicians and hospitals on their documentation, coding and billing. Susan previously served as a Fair Hearing Officer and HCFA Quality Coordinator for a Medicare carrier in Georgia.

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PREOPERATIVE DIAGNOSIS: STATUS POST COLON RESECTION AND COLOSTOMY FOR ADENOCARCINOMA

POSTOPERATIVE DIAGNOSIS: SAME WITH THE SMALL TRANSVERSE COLONIC POLYP

OPERATION: FLEXIBLE COLONOSCOPY WITH POLYPECTOMY

ANESTHESIA: IV SEDATION WITH DEMEROL AND VERSED

INDICATIONS: Patient had previously undergone a left hemicolectomy with colostomy and subsequently and colostomy take-down and re-anastomosis. Endoscopy was to rule out recurrent disease.

PROCEDURE: The patient was taken to the Endoscopy Suite where under intravenous sedation, careful palpation of the perianal canal revealed no obvious pathology. The flexible colonoscope was then introduced per anus and passed carefully to the level of the cecum. The cecum and the ascending colon were within normal limits. Right at the hepatic flexure was a small polyp which looked to be the side of his colostomy take-down. Again this measured maybe 3mm in diameter and I used the snare to excise that. The rest of the transverse colon, descending colon and rectum were within normal limits. The endoscope was withdrawn. The patient tolerated the procedure satisfactorily.

PREOPERATIVE DIAGNOSIS: STATUS POST COLON RESECTION AND COLOSTOMY FOR ADENOCARCINOMA

POSTOPERATIVE DIAGNOSIS: SAME WITH THE SMALL TRANSVERSE COLONIC POLYP

OPERATION: FLEXIBLE COLONOSCOPY WITH POLYPECTOMY

ANESTHESIA: IV SEDATION WITH DEMEROL AND VERSED

INDICATIONS: Patient had previously undergone a left hemicolectomy with colostomy and subsequently and colostomy take-down and re-anastomosis. Endoscopy was to rule out recurrent disease.

PROCEDURE: The patient was taken to the Endoscopy Suite where under intravenous sedation, careful palpation of the perianal canal revealed no obvious pathology. The flexible colonoscope was then introduced per anus and passed carefully to the level of the cecum. The cecum and the ascending colon were within normal limits. Right at the hepatic flexure was a small polyp which looked to be the side of his colostomy take-down. Again this measured maybe 3mm in diameter and I used the snare to excise that. The rest of the transverse colon, descending colon and rectum were within normal limits. The endoscope was withdrawn. The patient tolerated the procedure satisfactorily.

PREOPERATIVE DIAGNOSIS: STATUS POST COLON RESECTION AND COLOSTOMY FOR ADENOCARCINOMA

POSTOPERATIVE DIAGNOSIS: SAME WITH THE SMALL TRANSVERSE COLONIC POLYP

OPERATION: FLEXIBLE COLONOSCOPY WITH POLYPECTOMY

ANESTHESIA: IV SEDATION WITH DEMEROL AND VERSED

INDICATIONS: Patient had previously undergone a left hemicolectomy with colostomy and subsequently and colostomy take-down and re-anastomosis. Endoscopy was to rule out recurrent disease.

PROCEDURE: The patient was taken to the Endoscopy Suite where under intravenous sedation, careful palpation of the perianal canal revealed no obvious pathology. The flexible colonoscope was then introduced per anus and passed carefully to the level of the cecum. CPT 45378 The cecum and the ascending colon were within normal limits. Right at the hepatic flexure was a small polyp CPT 45385 which looked to be the side of his colostomy take-down. Again this measured maybe 3mm in diameter and I used the snare to excise that. CPT 45385 The rest of the transverse colon, descending colon and rectum were within normal limits. The endoscope was withdrawn. The patient tolerated the procedure satisfactorily.

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