ICD-10 Surgery Codes – Essentials for Appropriate Reimbursement

by | Published on Nov 18, 2016 | Medical Coding

Surgery Codes Essentials
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Today, most general surgery practices and departments of surgery rely on experienced medical billing and coding companies to ensure that claims get paid. However, accurate documentation of procedures is necessary for coders to translate the services performed into the correct codes for appropriate reimbursement. The American College of Surgeons reported that the results of private audits revealed that there was a lot of scope for improvement in surgical documentation. Surgeons missed out on reimbursement due to undercoding of the procedures performed. Here are the areas that surgical practices have to focus on to avoid rejected claims and ensure appropriate payment for their services:

    • Specificity and laterality: The end of the ICD-10 grace period means that there will be no more concessions for the use of unspecified codes and not coding for laterality and anatomical specificity. Examples of ICD-10 documentation for general surgery:
      • Breast cancer: ICD-10 code category C50 (malignant neoplasm of the breast) includes laterality (right vs. left) as well as anatomical specificity (e.g., nipple and areola, central portion, lower inner quadrant) – both of these must be included in medical record documentation.
      • Neoplasms: ICD-10 has separate codes for benign neoplasms of the cecum (ICD-10 code D12.0), appendix (ICD-10 code D12.1), ascending colon (ICD-10 code D12.2), transverse colon (ICD-10 code D12.3), descending colon (ICD-10 code D12.4), and so on. Documentation should specify site and laterality such as: main bronchus, left lower lobe of lung.

      However, unspecified ICD-10 codes may be used when patient is seen for the first time and the diagnosis is unknown.

    • Documentation of comorbidities: Coding just the primary condition will leave revenue on the table. Comorbidities should be documented in detail to show their impact on the patient’s condition even if it is not the primary problem. Payers will get a more complete picture of the patient’s health status and the complexity of care delivered only when comorbidities as secondary diagnoses are included. For example:
      • Transurethral prostatectomy – complications: hemorrhage, renal complications, infection; comorbidities: diabetes, arteriosclerotic heart disease, emphysema

      With the focus on value based reimbursement, comorbidity diagnoses and other aspects of a patient’s history could impact healthcare providers’ ability to negotiate bundled payments and also establish medical necessity of a procedure.

    • Personal history codes: Reporting personal and family history codes that are relevant to the patient’s treatment is important. Regardless of how experienced the medical coding service provider is, accurate coding cannot be ensured if the surgeon does not report the patient’s personal history. For instance, if the patient has secondary lung cancer, the general surgeon should report not only the primary location but also all the affected sites.

      Categories Z85-Z99 are the personal history codes; categories Z80 to Z84 are the family history codes and include neoplasms, heart disease, nervous system disorders, mental health disorders, digestive disorders, and other conditions.

    • Overlapping sites: Overlapping sites codes are a unique feature of ICD-10. In the case of neoplasms, overlapping lesion codes should be used instead of codes for each specific area. The selection of the overlapping code series depends on the part of the body. Examples:
      • Colorectal neoplasms: C18.8, malignant neoplasm of overlapping sites of colon
      • Neoplasms of pancreas: C25.8, malignant neoplasm of overlapping sites of pancreas

Skilled AAPC-certified coders in reliable medical coding companies are well aware of ICD-10 requirements. They will work with providers to ensure accurate documentation and provide general surgery medical billing and coding services for optimal reimbursement. If there is missing information in the patient’s medical record, they will ask the surgeon for more details so as to ensure coding with the necessary specificity and prevent claim denials.

Julie Clements

Julie Clements, OSI’s Vice President of Operations, brings a diverse background in healthcare staffing and a robust six-year tenure as the Director of Sales and Marketing at a prestigious 4-star resort.

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