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You think you’ve done everything you can to improve billing and claims filing processes: computerized systems, electronic filing, and even tickler files that tell you when to follow-up with managed care companies regarding payment. The one area that is often overlooked is the documentation needed by the coder to accurately code the claim, say experts interviewed by Hospital Payment & Information Management.
If the claim isn’t coded correctly, the claim is denied or paid at a lower rate than you might be due, says Cheryl D’Amato, RHIT, CCS, director of health information management for HSS, a Hamden, CT-based company that specializes in coding and payment for health care facilities.
Accurate coding depends on documentation from the surgeon, and there are many same-day surgery procedures that often are not fully documented, says D’Amato. "Wound repair, arthroscopy, biopsy, and debridement are commonly the most difficult to code because the documentation is incomplete," she says.
Although physicians capture enough detail for their own billing, operative reports are generally not as specific, says Rita A. Scichilone, MHSA, RHIA, CCS, CSCP, CHC, director of the coding program for the American Health Information Management Association in Chicago. This is why it is good to have a strong working relationship with the physician’s office staff, she suggests. "Whenever possible, compare the reimbursement or claim filed for professional fees with the claim filed for facility fees," she recommends. "This will enable the coder to identify details of the procedure not included in the operative report."
Arthroscopy is a good example of a procedure in which documentation for coders is often scant, says Scichilone. "The surgeon will write that he or she did a scope’ but doesn’t define whether it was diagnostic only or if a procedure followed the approach." If there is another procedure such as a meniscectomy, the use of the scope to approach the area is not reimbursed, but the following procedure is, she adds.
Debridement is another area that requires detailed documentation, says D’Amato. "There are different codes for different levels of debridement. Skin and subcutaneous level is coded differently than debridement that involves bone and muscle."
Surgeons also need to document the use of additional techniques to enable the coder to include them on the claim, points out Scichilone. "If a wire locator is used or if a CT or fluoroscope is used for guidance, the surgeon must write those specific techniques in the operative report," she says. "Otherwise, the coder does not even know about them and can’t include them in a claim without documentation."
There are several ways a same-day surgery manager can improve documentation that will help coders. "Teach your nurses and physicians about coding," says Scichilone. Show examples of claims that are coded with general, nonspecific documentation compared with claims that are coded with detailed documentation, she suggests. The difference in reimbursement will point out the importance of detailed coding. Educate your coders as well, adds Scichilone. "Sometimes an incorrect pain management code is simply the coder not understanding epidurals or different types of joint injections," she says.
Recognize that your coders need as much detailed information as possible, says D’Amato. "Some facilities also insist that coding will not occur until the full operative report and the pathology report is in the record," suggests D’Amato. The pathology report is especially helpful when the procedure was for biopsy, she explains. Make sure you have a process set up for coders to send the records back to the physician for more information, says D’Amato. This will enable them to code the claim correctly, she adds.
This process can involve a designated contact person in the physician’s office or simply e-mails to the physician’s own address, says Scichilone.
Templates also can be set up for operative reports, says D’Amato. "These forms can remind the surgeon to document the patient’s comorbidities such as diabetes or hypertension. Forms also can prompt documentation of details such as length of wound repaired or depth of debridement."
Be careful with forms you use. "Boilerplate" reports may overlook some changes made during a case or not report some of the details, same-day surgery administrators point out. "Stay away from canned reports that don’t vary from procedure to procedure," Scichilone warns. "If all of your operative reports look exactly the same, managed care companies might suspect falsification."