How to Make Codes as Specific as Possible in Medical Billing

In addition to choosing the right code in medical billing, you also need to ensure that the assigned code is specific to the procedure. Just as you rely on the physician to be as specific as possible in his or her documentation, the physician relies on you to assign the most accurate codes possible.

For this process to work as it should, two things need to happen, in the following order: First, the physician needs to document correctly so that you can choose the appropriate procedural code. Second, you use the physician’s documentation to choose the correct CPT code.

In the physician documentation, the physician must clearly state and describe the procedure that was performed. Here’s an example of good documentation; it has everything you need to select the correct codes:

A longitudinal incision was made to the radial aspect of the DIP joint of the left index finger. Subcutaneous dissection was blunt. Obvious ganglion was identified. The connection to the joint between the extensor tendon and collateral ligament was identified. Joint was opened, and the cyst was entirely removed, leaving ligaments intact. Wound was irrigated. A vicryl stitch was placed between tendon and ligament. Skin was closed, and dressing applied.

Seems simple enough, right? Unfortunately, you’ll occasionally encounter the following problems, which need to be resolved before you can assign the proper codes:

  • A physician simply dictates that he performed a specific procedure, but instead of describing the procedure, he uses a CPT code. For example, “I then performed a CPT 29828.” This type of entry doesn’t satisfy documentation requirements. The physician must describe the procedure in detail before you can code and bill it.

    Proper documentation of a surgical procedure includes a brief history of the patient’s problem, a good dictation of the approach taken, any structures affected by the approach, a clear description of what was done while inside the patient, any complications that may have arisen, and an explanation of the closure and recovery.

  • A physician may consistently fail to document a particular procedure, saying, “That’s what I always mean when I say that.” Unfortunately, his intentions don’t constitute proper documentation. The physician must clearly state and describe the procedure that was performed each and every time he performs it.

    If you’re dealing with a doc who habitually makes these documentation assumptions, you may have to produce the necessary documentation—that is, show him the description of the procedure as published by the AMA or CMS — so that he agrees to comply. Doing so is more work for you, but it pays off big time later when you file that clean claim.

In these situations, you need to get the missing information; after all, it’s the physician’s job to describe procedures, and it’s your job to code them, not the other way around. However, how you go about filling in the documentation blanks is very important. You can’t ask leading questions, for example, because doing so can lead to fraudulent coding and excessive reimbursement.

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