Professional medical billing and coding services go a long way in ensuring appropriate reimbursement for claims submitted for payment. Optimizing operative coding is best accomplished with such expert support.
Trained and experienced coders would be able to overcome the challenges associated with coding surgical procedures, such as incomplete physician documentation, operative notes that lack clarity, multiple procedures, modifiers and compliance problems. Moreover, notable Current Procedural Terminology (CPT) coding changes are being implemented in 2016, with some changes reversing last year’s temporary coding for endoscopy procedures. Reliable medical coding companies keep track of these developments and are aware about the codes that are relevant to general surgery and its related specialties. Outsourcing the medical coding task is therefore the best option to secure maximum payment.
Coding correctly from the operative report involves the following steps:
- Checking the demographic information: The first thing that the coder will check is the patient details given in the report for accuracy. This includes the patient’s name, age, medical record number, the date and location of the surgery, the surgeon, resident assistant, anesthetist, and type of anesthesia. Besides determining if the physician referenced the right patient, coders will also check if any of this information is needed for abstracting purposes.
- Evaluation of the pre- and post-operative diagnoses: The diagnoses are general statements about the reason for the surgery and the operative note will have more details on diagnosis. Experts in ICD-10 coding will examine the diagnostic statement for the ulcer to get the additional details needed for coding the type, location, laterality, and stage of the ulcer. The operative note is the full report of all the surgical procedures performed and it will be different from the pre-operative report. There may be a second post-operative diagnosis for the ulcer due to what was found during the surgery.
- Checking whether all procedures performed are listed: This is done to ensure that the procedures documented within the report are also listed in the header. If these are different, the coder will check with the surgeon to learn what actually took place during the surgery. A modifier may have to be used to indicate extra work done. Every nuance would be documented such as:
- Procedure takes longer than expected
- Could not perform what was planned
- Unexpected findings during surgery
- Checking for complications. If the surgery involved complications, experienced coders will use additional codes for them.
- Read the procedures performed carefully: Expert coders know how important this is for ICD-10 PCS code assignment.
In addition to this, well-informed certified coders in a professional medical coding company will note the type of tissue removed in order to get more information on the procedures performed.
It is obvious that only a company with experience in providing medical billing and coding services will be able to help surgeons submit accurate claims and get paid promptly and appropriately.