CPT copyright 2010 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
Lolita M. Jones, RHIA, CCS, an independent consultant specializing in hospital outpatient and ambulatory surgery center coding, billing, reimbursement and operations, discusses seven common coding errors for six ASC specialties.
General surgery
1. Intermediate wound repairs. When a patient comes to the ASC to have a lesion excised, there is frequently a wound defect following the excision that has to be closed before the surgery is completed, Ms. Jones says. In this case, the physician will state a layer closure or intermediate wound repair was performed after the excision. Coders can assign an extra code and generate a different payment if there is a layer closure or intermediate wound repairs, but Ms. Jones stresses that only closures that apply to subcutaneous tissue can be considered "layer closures." If the physician says he or she performed a layer closure but does not indicate which tissues were closed, the coder should not report the procedure as a layer closure.
In the case of a closure that does not affect the subcutaneous tissue, Ms. Jones says coders should use the code for a simple repair. "If the physician just says layer closure and doesn't document tissues closed in the body of the op report [and you still code for a layer closure], you're generating money you're not entitled to," she says.
2. Spermatic cord lipoma. In the July 2000 CPT Assistant, the AMA clarified that when a patient comes to the ASC for an inguinal hernia repair and a spermatic cord lipoma is excised in the same operative session, coders can assign a separate code for the spermatic cord lipoma. "The procedures are considered distinct," she says. "I find a lot of ASC coders are still not reporting that separately. They look at it as part of the inguinal hernia repair and end up leaving money on the table."
Orthopedic surgery
3. Chronic versus acute rotator cuff repair coding. Ms. Jones says she frequently sees inconsistencies in chronic versus acute rotator cuff repair coding that could trigger a claim being suspended or even audited. According to the CPT codebook, there are separate CPT codes for repairing an acute rotator cuff and a chronic rotator cuff. "When I do audits, coders will have an acute CPT code but a chronic diagnosis code for rotator cuff repair, or vice versa," she says. "This is a big issue, especially if you're dealing with workers' compensation." Because workers' compensation is concerned with on-the-job injuries, there is a big difference between an acute injury (sustained during the on-the-job injury) and a chronic injury (which predated the on-the-job injury). She says this problem can also affect non-workers' compensation cases and could lead to an audit. She says the problem lies with coder error, possibly because of the sheer volume of rotator cuff repairs for some orthopedics-driven ASCs.
4. Ankle ligament repairs. Ms. Jones says there are two CPT codes for ankle ligament repairs. One code (CPT 27695) should be used if only one collateral ligament is repaired. The other code (CPT 27696) should be used if both collateral ligaments are repaired. Providers who fail to code for both — if both are repaired — will generally leave money on the table because most payors pay more for both ligaments than for one.
Oculoplastic surgery
5. Droopy eyelid, or blepharoptosis. There are two CPT codes for blepharoplasty, or surgical modification of the eyelid. The first code (CPT 15822) is used for normal blepharoplasties of the upper eyelid, whereas the second code (CPT 15823) is assigned when the patient has excessive skin weighing down the eyelid. The procedure automatically involves the removal of redundant skin, so the second code applies when the patient has excessive redundant skin. Ms. Jones says one hallmark that indicates a need for CPT 15823 is a "superior visual field defect," which should be indicated in the body of the operative report.
Gynecology
6. LEEP. The loop electrosurgical excision procedure is performed to cut out abnormal tissue in the cervix. When the LEEP is performed with no scope involved, the coders should use CPT 57522. More recently, however, Ms. Jones is noticing providers performing LEEP with a colposcope, requiring a completely separate code (CPT 57461). Since the procedure without the scope pays a lot more than the procedure with the scope, providers who code CPT 57461 when a scope was not involved walk away with more money than they are entitled to. "When [coders] are reading the operative report, they may just ignore the reference to the colposcope because it's not routinely used," Ms. Jones says.
Ophthalmology
7. Complex retinal detachment repair. Ms. Jones says she frequently finds that coders use CPT 67113 (complex retinal detachment repair) if the physician simply writes the word "complex" in the title or body of the operative report. The word "complex" does not justify the complex retinal detachment repair code, she says. Instead, the code's description in the CPT codebook gives examples of when the code should be used: if the patient has a retinal tear greater than 90 degrees, for example, or if the patient has diabetic traction retinal detachment. Coders should only indicate the procedure is a complex retinal detachment repair if the procedure meets the specified criteria.
The information provided should be utilized for educational purposes only. Please consult with your billing and coding expert. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.
Lolita M. Jones, RHIA, CCS, an independent consultant specializing in hospital outpatient and ambulatory surgery center coding, billing, reimbursement and operations, discusses seven common coding errors for six ASC specialties.
General surgery
1. Intermediate wound repairs. When a patient comes to the ASC to have a lesion excised, there is frequently a wound defect following the excision that has to be closed before the surgery is completed, Ms. Jones says. In this case, the physician will state a layer closure or intermediate wound repair was performed after the excision. Coders can assign an extra code and generate a different payment if there is a layer closure or intermediate wound repairs, but Ms. Jones stresses that only closures that apply to subcutaneous tissue can be considered "layer closures." If the physician says he or she performed a layer closure but does not indicate which tissues were closed, the coder should not report the procedure as a layer closure.
In the case of a closure that does not affect the subcutaneous tissue, Ms. Jones says coders should use the code for a simple repair. "If the physician just says layer closure and doesn't document tissues closed in the body of the op report [and you still code for a layer closure], you're generating money you're not entitled to," she says.
2. Spermatic cord lipoma. In the July 2000 CPT Assistant, the AMA clarified that when a patient comes to the ASC for an inguinal hernia repair and a spermatic cord lipoma is excised in the same operative session, coders can assign a separate code for the spermatic cord lipoma. "The procedures are considered distinct," she says. "I find a lot of ASC coders are still not reporting that separately. They look at it as part of the inguinal hernia repair and end up leaving money on the table."
Orthopedic surgery
3. Chronic versus acute rotator cuff repair coding. Ms. Jones says she frequently sees inconsistencies in chronic versus acute rotator cuff repair coding that could trigger a claim being suspended or even audited. According to the CPT codebook, there are separate CPT codes for repairing an acute rotator cuff and a chronic rotator cuff. "When I do audits, coders will have an acute CPT code but a chronic diagnosis code for rotator cuff repair, or vice versa," she says. "This is a big issue, especially if you're dealing with workers' compensation." Because workers' compensation is concerned with on-the-job injuries, there is a big difference between an acute injury (sustained during the on-the-job injury) and a chronic injury (which predated the on-the-job injury). She says this problem can also affect non-workers' compensation cases and could lead to an audit. She says the problem lies with coder error, possibly because of the sheer volume of rotator cuff repairs for some orthopedics-driven ASCs.
4. Ankle ligament repairs. Ms. Jones says there are two CPT codes for ankle ligament repairs. One code (CPT 27695) should be used if only one collateral ligament is repaired. The other code (CPT 27696) should be used if both collateral ligaments are repaired. Providers who fail to code for both — if both are repaired — will generally leave money on the table because most payors pay more for both ligaments than for one.
Oculoplastic surgery
5. Droopy eyelid, or blepharoptosis. There are two CPT codes for blepharoplasty, or surgical modification of the eyelid. The first code (CPT 15822) is used for normal blepharoplasties of the upper eyelid, whereas the second code (CPT 15823) is assigned when the patient has excessive skin weighing down the eyelid. The procedure automatically involves the removal of redundant skin, so the second code applies when the patient has excessive redundant skin. Ms. Jones says one hallmark that indicates a need for CPT 15823 is a "superior visual field defect," which should be indicated in the body of the operative report.
Gynecology
6. LEEP. The loop electrosurgical excision procedure is performed to cut out abnormal tissue in the cervix. When the LEEP is performed with no scope involved, the coders should use CPT 57522. More recently, however, Ms. Jones is noticing providers performing LEEP with a colposcope, requiring a completely separate code (CPT 57461). Since the procedure without the scope pays a lot more than the procedure with the scope, providers who code CPT 57461 when a scope was not involved walk away with more money than they are entitled to. "When [coders] are reading the operative report, they may just ignore the reference to the colposcope because it's not routinely used," Ms. Jones says.
Ophthalmology
7. Complex retinal detachment repair. Ms. Jones says she frequently finds that coders use CPT 67113 (complex retinal detachment repair) if the physician simply writes the word "complex" in the title or body of the operative report. The word "complex" does not justify the complex retinal detachment repair code, she says. Instead, the code's description in the CPT codebook gives examples of when the code should be used: if the patient has a retinal tear greater than 90 degrees, for example, or if the patient has diabetic traction retinal detachment. Coders should only indicate the procedure is a complex retinal detachment repair if the procedure meets the specified criteria.
The information provided should be utilized for educational purposes only. Please consult with your billing and coding expert. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.