If you think that provider’s notes and the anesthesia record are sufficient to know the details regarding cases and submit clean claims, you are missing out. The surgeon’s record can also contain information that can make or break your claim, such as case complexity or procedure changes.
Know the Case Complexity
“There are two things we identify most often when comparing the anesthesia documentation to the operative note,” says Cindy Hinton, CPC, CCP, CHCC, owner of Advanced Coding Solutions in Franklin, Tenn. “Number one is that we find that the procedure was more complex than expected.”
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Case: The anesthesia record includes a notation of “knee arthroscopy.” The operative note states that the surgeon completed debridement, repair, or reconstruction. Knowing that the surgeon performed something more than a diagnostic procedure can move you from reporting a code such as 01382 (Anesthesia for diagnostic arthroscopic procedures of knee joint) to 01400 (Anesthesia for open or surgical arthroscopic procedures on knee joint; not otherwise specified). The change from 01382 to 01400 means you’re entitled to report 4 base units instead of 3.
“The code series has diagnostic codes that often lead into surgical/therapeutic codes, depending on what is actually performed once the surgeon gets in there,” Hinton says. “That’s why there can be confusion.”
Check Out Thoracoscopy Differences
CPT® 2012 added several new codes for thoracoscopy (32666–32674), making those procedures tougher to report correctly, unless you study the documentation.
Example: It’s common to find notes such as “thoracoscopy with wedge”...
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