Surgery Coding Introduction

How to Code from Operative Reports with Confidence and Precision

How to Code from Operative Reports

Diagnosis Code Reporting:

• • Use the post-operative diagnosis for coding unless additional or further-defined diagnoses are found within the body of the operative report.
  • If available, utilize findings from the pathology report for diagnosis.
  • Example: If the post-op diagnosis confirms a benign lesion, but the pathology report reveals malignancy, the malignant code should be used.
• Start with Procedures Listed:
  • Always read the note entirely to verify procedures listed in the header.
  • Procedures in the header may not always be correct; cross-check with documentation in the body of the report.
  • Example: The header lists a laparoscopic appendectomy, but the body reveals the procedure was converted to an open appendectomy.
• Look for Key Words:
  • Focus on keywords like locations, anatomical structures, surgical approach (e.g., laparoscopic, open), procedure method (e.g., incision, drainage, repair), and other critical details.
  • Example: "Laparoscopic" cholecystectomy vs. "open" cholecystectomy – these keywords change the procedure code.
• Highlight Unfamiliar Words:
  • Research any unfamiliar terms to ensure accurate coding.
  • Example: If “arthrodesis” is unfamiliar, look it up to confirm it means the surgical immobilization of a joint.

• Read the Entire Report:
  • Every procedure reported should be documented within the body of the report.
  • Pay attention if procedures were abandoned or complicated, which might require modifiers or a different procedure code.
  • Example: Planned laparoscopic procedure converted to an open procedure due to complications, requiring modifier 22 for increased work.

Tips for Handling Operative Report Nuances:

• Modifications During Surgery:
  • If a procedure is more complicated or takes longer than expected, a modifier 22 may be necessary to indicate the additional work.
  • Example: A routine hysterectomy involves significant time due to dense adhesions, which must be documented to support modifier 22.
• Unable to Complete Planned Procedure:
  • If a planned procedure is abandoned or not fully performed, note the reason for using a different code or modifier.
  • Example: A full colonoscopy was planned, but due to twisted anatomy, the procedure was incomplete, requiring a code for a partial colonoscopy.
• Unexpected Findings:
  • Document additional procedures performed due to unexpected findings.
  • Example: During a laparoscopic cholecystectomy, a common bile duct blockage is discovered, requiring the procedure to be converted to an open surgery.

Documentation and CPT Codes:

• Preoperative and Postoperative Diagnoses:
  • Always document relevant pre- and post-operative diagnoses, including underlying conditions affecting the surgery.
  • Example: Pre-op diagnosis is “mass – unknown pathology.” Post-op diagnosis reveals “malignant tumor” based on pathology findings.
• Surgeon and Assistants:
  • Clearly differentiate between the primary surgeon, assistant surgeon, and co-surgeon roles.
  • Example: When two surgeons collaborate, ensure their roles are distinct to avoid confusion during coding.
• Procedures Performed:
  • Procedures should be documented in CPT terminology but avoid using CPT codes in the operative report.
  • Example: Instead of writing “CPT 29881,” document “partial medial meniscectomy.”
• Indications for Surgery:
  • Briefly explain the clinical necessity of the surgery, including past surgeries or the need for staged procedures.
  • Example: If it’s a planned stage of a wound reconstruction, note this to support modifier 58 (staged procedure).

Complexity and Additional Procedures:

• Modifier 22 – Increased Complexity:
  • Clearly document any additional complexity or time involved in the surgery to justify the use of modifier 22.
  • Example: An extensive lysis of adhesions that requires additional time and effort should be documented to support modifier 22.
• Details/Description of the Procedure:
  • Provide a detailed description, including patient positioning, anesthesia, special equipment used, and every action performed by the surgeon.
  • Example: Document “robot-assisted laparoscopic hysterectomy” to support billing for robotic assistance if relevant.

Steps for Accurate Surgical Coding:

1. Review the Header:
   • Check pre- and post-op diagnoses, procedures listed, and other key information.
   • Example: Pre-op diagnosis – osteoarthritis of the knee, post-op diagnosis confirms the same.
2. Review the CPT Code Book:
   • Verify potential CPT codes based on procedures documented.
   • Example: Arthroplasty of the knee has different codes depending on whether it’s a partial or total replacement.
3. Review the Documentation:
   • Check the body of the operative report for key details supporting the codes.
   • Example: Verify that the knee replacement involved only the medial compartment to support a unicompartmental code.
4. Make Preliminary Code Selection:
   • Based on the operative report, select the appropriate CPT code(s).
   • Example: A unicompartmental knee replacement is coded differently than a total knee replacement.
5. Review Guidelines for Preliminary Codes:
   • Double-check any relevant CPT guidelines to ensure compliance.
   • Example: Check whether specific technology used (e.g., robotic surgery) requires additional coding.
6. Review Policies and Eliminate Extras:
   • Review NCCI edits, local coverage determinations, and payer policies to ensure accurate code selection.
   • Example: Make sure bundled services or procedures that cannot be billed separately are excluded.
7. Add Necessary Modifiers:
   • Apply modifiers to indicate laterality, complexity, or staged procedures.
   • Example: Use LT to specify left knee when coding a knee replacement.

Separate Procedure

• Separate Procedures Overview

  • Some CPT-listed procedures are marked as “separate procedures” and are often part of a larger procedure.
  • Key Point: Separate procedures are not reported individually if they are integral to another service.

• Guidelines for Billing Separate Procedures

  • When to Report as Separate:
    • If the separate procedure is the only service provided, it can be reported individually.
    • If performed alongside another primary service as part of the main procedure, do not code the separate procedure.
  • Examples of Proper Billing Logic:
    • Diagnostic surgeries are often listed as separate procedures. If the diagnostic surgery is done alone without another surgical intervention, it should be billed independently.
    • If, during a diagnostic procedure, a condition is found, and an additional procedure (e.g., repair) is done, the diagnostic part becomes integral to the repair and is not separately billable.

• Examples for Understanding

  • Example 1:
    • Scenario: Patient James undergoes a diagnostic knee arthroscopy due to unresolved knee pain.
    • Finding: Only inflammation, no repair needed.
    • Billing Explanation: Since no additional surgery was performed, the diagnostic arthroscopy stands alone and is billable.
    • CPT Code: 29870.
  • Example 2:
    • Scenario: During the diagnostic knee arthroscopy, a tear in the medial meniscus is found and repaired.
    • Billing Explanation: Here, the diagnostic procedure is integral to the repair, so only the repair is coded, as the diagnostic portion is inclusive.
    • CPT Code: 29882.
• The diagnostic arthroscopy procedure is an integral part of the surgical procedure (the physician had to do the diagnostic portion to determine that there was indeed a tear; therefore, the diagnostic portion is “inclusive” of the actual repair and cannot be billed in addition to the procedure). This surgical procedure would be coded as 29882.

• Using Modifier -59 for Separate Procedures

  • When Applicable:
    • Modifier -59 should be used when the separate procedure is performed at the same session but is distinct and unrelated to the main procedure.
  • Situations for Modifier -59:
    • Different session or site, unrelated organ system, separate lesion/injury, or distinct surgical approaches.

• Example with Modifier -59:

  • Scenario: Dr. Smith performs a cranioplasty and drills a burr hole to place a ventricular catheter.
  • Billing Explanation: The burr hole is coded separately as it is significant and separate from the primary cranioplasty procedure.
  • CPT Codes: 62140 for cranioplasty, 61210 (modifier -59) for burr hole procedure.

• Additional Supplies/Materials

  • Some materials used during surgery, such as trays or drugs, may be billed separately if not typically included in standard surgery services.

Surgery Coding Introduction