Documentation is everything in healthcare. Providers and billing companies know this, and the expectations are not diminishing.
While documentation – at minimum – is a medical necessity, when performed with detail and accuracy, it also results in correct coding. Detailed documentation leads to better coding, which in turn improves the chances of being appropriately reimbursed for the services provided.
Many times, providers view coders as though they are “grading papers,” but this truly is not the intent. The role of a coder is to understand the documentation and to apply the appropriate codes. In doing so, coders play a major role in reimbursement and, relatedly, overall revenue for the practice or group.
When documenting a procedure, it is important to be as accurate and detailed as possible to support coding efforts. For instance, laterality and location must be carefully noted, as reimbursement can be affected by even the smallest missing detail.
To demonstrate the intricacies of documentation and coding, I’d like to share an example in the anesthesia space. During the coding and billing process, an anesthesia coder reviews the anesthesia documentation before anyone else, making their role critical.
Many surgical Current Procedural Terminology (CPT®) codes have multiple options for the Anesthesia CROSSWALK® (ASA) code, and therefore there’s a possibility for varying base unit values. Without detailed documentation, a coder may default to a lower base unit.
Ideally, a coder works with a variety of different reports, including anesthesia records, operative reports and even pathology reports. Oftentimes, however, they’re faced with missing or unavailable documentation that makes coding a challenge. If a coder does not have access to an Ambulatory Surgical Center’s database, for instance, the operative record may not be available to be viewed. Or perhaps they have the Anesthesia Pre-Op Evaluation, but cannot rely on it because procedures commonly change mid-case. In either situation, the coder must rely solely on what the Anesthesiologist documents, making it all the more important that the anesthesia record is updated at the conclusion of the case to capture any changes and procedure details.
A Transurethral Resection of a Bladder Tumor (TURB) is a perfect example because the size of the tumor matters for reimbursement.
52234 – SMALL bladder tumor 0.5 up to 2.0 cm
52235 – MEDIUM bladder tumor 2.0 up to 5.0 cm
52240 – LARGE bladder tumor 5.0 cm +
Each of the above CPT codes crosses to 00912 (worth 5 base units). However, anything under 0.5 cm is considered a MINOR tumor and uses 52224 with ASA 00910 (worth only 3 base units).
If the anesthesiologist only documents TURB on their record, and the operative note is not available, coding parameters allow the coder to default to the lesser code 52224. Simply documenting the size of the tumor on the anesthesia record would allow for accurate coding, which could result in greater reimbursement.
Below are a few additional examples of procedures where lesser documentation affects reimbursement:
- GI cases – document if the work was done in the upper or lower abdomen; coders cannot assume, and at times, the operative report is not clear.
- Spinal cases – document the vertebrae involved AND if instrumentation was involved.
- Hernias – document if the work was done in the upper or lower abdomen, but also document if reducible or incarcerated/strangulated.
Clear and detailed documentation sets coders up for success to best drive appropriate reimbursements. Additionally, it reduces the need to query the provider, leading to an easier and uninterrupted revenue cycle.
As a coder, I work with my providers to help guide them in terms of accurate documentation that will withstand any payor post payment audit. If you have specific questions about coding or documentation, please feel free to contact us directly for support.
Dawn Davis, CPC, CANPC