Open Surgical Procedures Medical Billers and Coders Encounter

By Karen Smiley

Open surgery refers to traditional surgical procedures, which involve an ­incision made by a surgeon. Obvious differences exist between endoscopic and open surgical procedures from a coding position. The distinction between ‐otomy versus ‐oscopy may seem minor, but it makes a big difference.

Being able to recognize such subtle differences between terms is why a solid knowledge of human anatomy and medical terminology is so important. Without it, you won’t be able to tell one type of procedure from another.

Coding the open surgical procedure

When you sit down to code an open procedure, you see the operative report, which includes the following:

  • A heading that identifies the patient, the date and location of the surgery, the physician, his assistant and other demographic information.

    The first step in abstracting the billable codes from the medical record of an open procedure is to identify which body part was treated and why. After you have identified that, you know which area of the CPT book to check to begin the process of coding.

  • A preoperative, or preliminary, diagnosis, which is the diagnosis based on preoperative testing and pertinent physical findings observed by the physician during the examination.

  • The postoperative, or definitive, diagnosis, which is what the physician confirmed during the surgery.

  • A summary or outline of the procedures performed.

    Do not code procedures from the outline in the report! These headings are merely previews of what is to come. Regardless of what the heading says, for a procedure to be eligible for reimbursement, it must be documented in the body of the report.

  • A full report containing the surgeon’s description of everything that he did during the operation.

The documentation for the procedure should always be described in the body of the report. If the body of the report does not contain something that is mentioned in the heading, then the physician must correct the documentation before it can be reported. Remember the mantra of the medical coder: “If the doctor didn’t say it, it wasn’t done.”

Initiating a physician query

To get the missing information, you can initiate a physician query via a handwritten note (some facilities have a query form just for this purpose), or you can ask the surgeon directly for clarification if you work in an environment in which a direct query is possible. After you get an answer and if the record needs to be altered, the surgeon must dictate an addendum (add to the note), or he may dictate a corrected note.

When initiating a physician query, make sure that you don’t lead the physician with regard to verbiage. Here are some examples of leading verbiage and more appropriate alternatives:

Leading Non‐leading
Did the mass invade muscle tissue? How deep was the mass?
Did you excise over one centimeter
of the clavicle?
How much of the clavicle did you remove?

Let the physician describe the work performed without putting words in his or her mouth.

Understanding incidentals and unbundling

The surgeon may indicate that a certain procedure was extra or required additional time and skill on her part. If this extra work is well documented, it may support unbundling.

Unbundling procedures are affected by something called the National Correct Coding Initiative (NCCI) edits, which are the Medicare version of what is and isn’t included or exclusive to other procedures. Most editing software programs are based on these edits. If the NCCI edits indicate that the procedures are bundled, then the physician must have documented that the procedures required additional skill and time before they can be billed separately.

For example, during a surgery, the surgeon has to make an incision, which is not billable. At the conclusion of the procedure, the surgeon needs to repair the incision, which is also not billable.

Now, if the repair is more than what would be necessary to close the incision — say the surgeon has to rearrange tissue to improve the appearance of the scar — then the repair may be eligible for additional reimbursement, but the surgeon would have to document the additional work and the reason it was necessary. Otherwise, the procedure may be considered incidental and not separately billable.

As the coder, you’re responsible for verifying which procedures are ­incidental and which ones are eligible to unbundle.

Using billing modifiers

Certain modifiers are appropriate for surgical or diagnostic procedures; other modifiers are appropriate for claims submitted for reimbursement of office visits, referred to in the coding world as evaluation and management, or E&M, visits (covered in the next section). Here are the modifiers you’re most likely to use:

  • Modifier 25: You use this modifier when a procedure is performed on the same day that an E&M visit occurred. This modifier indicates that the procedure wasn’t necessarily related to the E&M visit, and the provider feels that additional reimbursement is warranted because the E&M was significant and separately identifiable from the procedure.

  • Modifier 51: This modifier indicates that multiple procedures have been submitted on one claim, and the appropriate discount may be applied.

    Most carriers pay 100 percent of either negotiated rates or fee schedule reimbursement for the first procedure. Then additional procedures are paid at 50 percent of fee schedule, although some commercial payer contracts pay 25 percent of the third (or remaining) procedure(s) on each claim. Medicare pays 100 percent and 50 percent, regardless of the number of codes submitted. Other payer contracts may limit the number of procedures paid per encounter. Check your provider’s contract to know exactly what amount to expect.

  • Modifier 59: You use this magic modifier to indicate that a procedure being billed is normally included with another procedure or encounter but warrants separate consideration.

    Effective January 5, 2015, using Modifier 59 requires addition of a second, informational modifier. Medicare claims after this date require both modifiers, and private payers will likely follow suit.

    CMS made this decision because the 59 modifier had such a broad range of uses. It encompassed everything from separate encounters and different anatomic locations, in addition to distinct services. The modifier has become so widely used (or abused) that identifying exactly which edit was being bypassed was difficult.

    The new second modifiers are as follows:

    • XE Separate Encounter: The service is distinct because it occurred during a different encounter.

    • XS Separate Structure: The service was performed on a separate organ or structure (body part).)

    • XP Separate Practitioner: The service was performed by a different practitioner.

    • XU Unusual Non‐Overlapping Service: A service was used that shouldn’t overlap the usual components of the main service or procedure.

Correct reimbursement may depend upon using the appropriate modifier, and you’re responsible for understanding which modifier to use when. But be careful. If you overuse or incorrectly use them, the provider can get into trouble.