Procedure & Operative Reports Affect Reimbursements

As coding becomes more challenging with the implementation of ICD-10-CM, CPT including bundling edits and modifiers, the importance of an accurate source document to assure accurate code(s) is important in all healthcare settings.

The Current Procedural Terminology (CPT) system, developed by the American Medical Association (AMA), is used to report medical procedures and services performed by physicians and other qualified healthcare professionals for the development of guidelines for medical care review and processing of claims. The codebook is a compilation of guidelines, codes, and descriptions compiled in order to report medical procedures performed. Medical coding professionals abstract clinical data from health records and assign appropriate medical codes by applying appropriate coding guidelines representing the service(s) and/or procedure(s) performed during the patient encounter.  Anesthesia services are assigned with ASA code (00100-01999) from the current CPT manual. Ancillary services are assigned codes from the surgical and medicine sections of the manual. 

Medical necessity for the procedure is assigned with ICD-10 codes, developed by the World Health Organization (WHO) and maintained domestically by a collaboration of several entities including the National Center for Health Statistics (NCHS), Centers for Medicare and Medicaid (CMS) and the American Hospital Association (AHA).  This set of codes is reported based on the reason or diagnosis documented by the provider. The coded information reported on the CMS-1500 claim form is used for carrier reimbursement for the service(s) provided.

In the specialty of anesthesia, coders abstract codes from the anesthesia record; pre, intra, and post for the anesthesia service.  As the specialty of anesthesia is different from other specialties, the rules, and guidelines are unique. What does a coder do when the anesthesia record is missing an element or presents conflicting information? Coders may seek to review the documentation from an operative report to satisfy these obstacles. While this may sound like a reasonable or even welcomed alternative, it is not without concerns and challenges. As previously mentioned, anesthesia is unique. The guidelines that are relevant to anesthesia are not pervasive to surgical specialties, meaning there are risks of missed opportunities. Keep in mind, it is the anesthesia provider’s name on the claim. Ideally, the codes sent for reimbursement should be represented from their documentation. The easiest way to fulfill this is to ensure your documentation is complete through an accurate template and with details obtained by the surgeon at the conclusion of the encounter.     

A procedure note completed by the anesthesia provider is required for ancillary services. Typically templated and tailored to the most common ancillary services, the documentation fulfills the elements required from all specialties that report surgical and/or medicine section codes.  These services should have a supporting procedure note to substantiate the encounter with the patient. Every procedure note consists of the following components: name of the procedure, indications for surgery, description of the procedure, findings and follow-up required for the patient, and finally, the identification of the healthcare professional who performed the service.  Anesthesia providers should also consider documenting ‘when’ the procedure was performed for time determinations related to any anesthesia services.  

ACE can help you analyze your documentation efforts and assist you with any improvement that may be needed.

Contact us today to learn more about our coding review services. 


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