Coding: It’s All in the Details

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.

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.