Q&A Coding complex procedures...

[BrenethG]

In a complex procedures, like surgery. What are we looking here to code for? and how do we sequence multiple codes?any tips please... thanks (This is a general question on any complex surgical procedure. I am an EMR user and saw half to one page of doctor's note on surgical procedure. I wonder how to put codes on these multiple procedures done at the same time in the OR, Radiology is there, supplies used, consultations thru phone and surgical team present in the operating room.)

 

[Lori Woods]

Laureen Jandroep at CCO made this video that I like.

As a Medical Coding Professional, when you sit down to code an open procedure, you need to see the operative report, which includes the following:

• A heading that identifies the patient, the date and location of the surgery, the physician, 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.”

 

[BrenethG]

Thank you so much Lori and Laureen for the great inputs

 

[Alicia Scott]

Praticode would helpful here also for practice.