Documentation is the key instrument in assigning correct CPT codes and the most common means of communication among the clinical and administrative staff. The most common types of source documentation include a surgical (operative report); procedure report; dictated record of the physician's findings, superbill, charge ticket or fee slip.
When reading the source document (whether dictated or handwritten), it is important to identify the indication for the procedure (diagnosis or symptom), the procedure being performed and whether the procedure being performed must be identified this includes:
Diagnostic or therapeutic procedure or service
Approach - endoscopic; incisional; excisional; repair; introduction or removal; biopsy, percutaneous or other
Components of the procedure performed
The level of key components performed
Coders must be able to identify sentences that describe findings or comments. For example, "after introduction of the cystoscope, a ureteral stricture was observed." These sentences are information, and do not describe the actual procedure. However, they do include important information supporting the medical necessity (or need) for the procedure.
The "action" sentences of an operative report are those that describe the actual procedure. Action sentences are most important for coders. For example, "A cone-tipped catheter was inserted via the cystocscope, and a bilateral retrograde pyelogram was performed." CPT/HCPCS codes are assigned based on the action sentences the physician provides. However, you must read the entire report. You cannot code just from the action statement.
Multiple components of a procedure may be performed, such as cystoscope with pyelogram and cystoscopy with uretral stent placement. When this occurs, the hospital l claim should include multiple CPT codes from the surgery section to describe the various components of the procedure. Follow the payer guidelines for component billing (such as unbundling edits) when billing for the professional service.
In addition to the surgical codes, facility coders would assign radiology HCPCS codes for the technical component based on the description of the imaging portion of the procedure. The provider who performed the supervision and interpretation of the adiologic portion of the procedure would bill the professional component.
The "closure" sentences in an operative report give detailed information about the termination of the procedure, including the instrument removal, sutures and other closures, dressing applications and, if appropriate, discharge instructions and follow-up care. Normally, these descriptions do not affect code assignment. However, it would be affected in cases where additional surgical codes are assigned to describe manual or manipulation procedures or a closure over and above the normal, such as a layer closure after the removal of a skin lesion.
Coders must be careful when assigning multiple codes to describe procedures performed, since some codes are inclusive of various components (for example, catheter insertions, and calibrations). Evaluate the text for each CPT code and the medical/surgical practice standards. Failure to utilize coding guidelines and appropriate codes may reflect the inappropriate process of bundling or unbundling of procedures.
How to assign a code:
When assigning a CPT code to a procedure or service performed, certain steps must be followed to ensure that you make the most accurate and complete choice.
1. Select the procedure to be codes from the documentation provided
2. Identify the main terms and/or subterms to be located in the index which lists four primary types of entries: procedure or service; organ or anatomical site; condition; and synonym, eponym or abbreviation.
3. Identify the main term
4. Check subterms below the main term and select the appropriate code. never code directly from the index as it is only a guide for the tabular section of the CPT manual. Refer to the tabular section of the book, and identify the code that you have chosen.
5. Read the notes provided including those at the beginning of the anatomical subsection
6. Read any instructions that appear in parentheses under the code
7. Verify the procedure description
8. Assign the code
9. If necessary, assign a modifier to the code.
This may be a helpful template to help break down the surgeries
Approach
Finding
Action
Closure
Comment
CPT Codes
Facility
Processional