ORLANDO, FL-Getting reimbursed properly for performing procedures is all in the details, especially in areas that can be confusing to code. This was the underlying message at a talk on CPT coding at the American Rhinologic Society (ARS) meeting at the recent annual Combined Otolaryngological Spring Meeting. The aim of the talk was to help residents and fellows improve this part of their practice.
Explore this issue:June 2008
You need to document in your chart exactly what you do, why you did it, and how you did it, said Michael Setzen, MD, Clinical Associate Professor of Otolaryngology at New York University School of Medicine, who practices in Long Island. He described how to code for several areas that can be confusing to code for, such as image-guided work, septoplasty, postoperative debridement, and other rhinologic procedures.
The three most important elements to keep in mind are documentation, medical necessity, and accurate coding, he said.
Don’t simply mark down I did nasal endoscopy, he said. Explain why it was done. Say you did nasal endoscopy because you wanted to evaluate the osteomeatal complex, you were looking for polyps, you saw pus exuding from the area. You want to document what you saw and what you did so that an insurance carrier can see a complete reason why you did the nasal endoscopy, he said.
Codes need to be correct, too. You need to code appropriately, fairly, and diligently. Because if not, you can get audited, and there are significant penalties. If CMS [the Centers for Medicare and Medicaid Services] or the government audits you, it’s like an IRS audit-it’s pretty severe, he said.
The coding needs to match the CPT code (the procedure code), and it needs to match appropriately with ICD-9 codes (the diagnosis codes). If a modifier is used, then that needs to be appended to the procedure code. For instance, if endoscopic sinus surgery (ESS) was done bilaterally, then a procedure code is needed for the left side, and a modifier is needed to show that the right side was also done.
Modifiers are there for you to notify the insurance carriers, so they can ultimately reimburse you, he said. Left and right side applies to other procedures, too. In short, all the information needs to be there.
Dr. Setzen cautioned doctors to code properly. If you code inappropriately, and upcode, you can make a lot of money. But if you get audited… there are significant penalties, and you can go to jail.
One tricky area to code for is image-guided surgery (IGS), largely because it is still often considered experimental and not standard care. According to expert opinion, IGS enhances endoscopic surgery, but there are few outcome studies because it is difficult to get large enough patient populations for them (about 50,000 patients are needed in outcomes studies to show statistical and clinical meaningfulness).