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Outpatient Surgery E-Weekly

Contact Congress Over Drug Shortage Issues

A Kentucky congressman is urging surgical facilities to contact their members of Congress and request that they sign his letter demanding changes to...

N.J. Posts ASC Inspection Reports Online

State and federal inspection reports of New Jersey's ASCs are now available online, giving patients an opportunity to make more informed choices abo...

Are Opioids Necessary?

While it's not always practical, or even possible, to eliminate opioids from your post-op pain management regiment, reducing their use in favor of n...

Archive > June, 2008 Vol. IX, No. 6

Coding & Billing

Are Your Surgeons Costing You Money?

Lolita M. Jones, RHIA, CCS

Do your op reports have gaps in the narrative that don't support the CPT code suggested by the procedure title? Such errors can delay claim submission while your coder awaits clarification from the physician. Worse, they can result in underpaid claims if the physician refuses to provide clarification or provides an inadequate response to the coder's query. Here are a dozen common documentation deficiencies.

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Complex Wound Repair; Extensive Upper Lid Blepharoplasty; Acute vs. Chronic Rotator Cuff Tear; Distal Radius Fracture Fragments; Flexor Tendon Zone Repair; Long or Short Saphenous Veins; Internal vs. External Hemorrhoids; Penile Adhesions; Hypospadias Repair; Size of Uterus Removed; Multiple Epidural Electrodes; Post-operative Anesthesia; AMA; Adhesions During; Anesthesia Numerous; Assign; Blepharoplasty; Blepharoplasty Physicians; CPT; Chronic Rotator Cuff Tear Without; Complex; Cuff Tear Without; Destruction; Electrodes Lots; Enucleation; Epidural Electrodes Lots; Excision; External Hemorrho... show all keywords
Complex Wound Repair; Extensive Upper Lid Blepharoplasty; Acute vs. Chronic Rotator Cuff Tear; Distal Radius Fracture Fragments; Flexor Tendon Zone Repair; Long or Short Saphenous Veins; Internal vs. External Hemorrhoids; Penile Adhesions; Hypospadias Repair; Size of Uterus Removed; Multiple Epidural Electrodes; Post-operative Anesthesia; AMA; Adhesions During; Anesthesia Numerous; Assign; Blepharoplasty; Blepharoplasty Physicians; CPT; Chronic Rotator Cuff Tear Without; Complex; Cuff Tear Without; Destruction; Electrodes Lots; Enucleation; Epidural Electrodes Lots; Excision; External Hemorrhoids Many; Foreskin; Fracture Fragments When; Fragments When; Hemorrhoids Many; Lid Blepharoplasty Physicians; Lysis; Open; Radius Fracture Fragments When; Removed Pathologists; Repair; Repair Many; Repair Some; Rotator Cuff Tear Without; Saphenous Veins Physicians; Short Saphenous Veins Physicians; Tear Without; Tendon Zone Repair Some; Upper Lid Blepharoplasty Physicians; Uterus Removed Pathologists; Veins Physicians; Wide; Work; Wound Repair Many; Wounds; Zone Repair Some; accurate; acuity; acute; addition; adhesions; administer; administration; advancement; anatomical; and/or; anesthesia; anesthetic; apply; area; arthroscopic; assign; assigned; assignment; avoid; awaits; based; benign; blepharoplasty; block; blocks; body; calf; case; catheters; causing; chordee; chronic; claim; clarification; closely; code; coded; coder; coders; codes; coding; common; complex; complicated; correct; crease; creating; critical; cuff; debridement; debriding; deep; default; defect; degeneration; delay; develop; diagnosis; digital; dissection; distal; distinct; distinction; distortion; division; document; documentation; dozen; droop; ears; edges; electrode; epiphyseal; errors; excess; excessive; excision; extends; extensive; external; extra-articular; eyelid; fact; fat; femoral; field; fixation; flaps; flexor; fold; fracture; fragments; free; gaps; general; give; graft; greater; groin; guidelines; hand; hemorrhoid; hypospadias; hysterectomy; impacts; implantation; inadequate; include; includes; including; information; injection; inside; internal; interphalangeal; intra-articular; island; joins; junction; knee; lacerations; laparoscopic; layered; lead; leg; lesions; lid; local; long; lysis; makes; malignant; man's; management; manipulation; meatal; mechanically; mid-palm; mobilization; multiple; musculotendinous; narcotic; narrative; nerve; neurostimulator; number; obscuring; obstruction; obtaining; occurs; official; one-stage; op; open; operative; orbital; orthopedic; pain; part; pathology; patient; penile; percutaneously; perform; performance; performed; performing; physician; physicians; place; placement; popliteal; portion; post-circumcision; post-op; post-operatively; preparing; prepucial; preputial; primary; procedure; proper; provide; published; radial; radius; receives; reconstruction; redistribute; reduction; redundant; references; refuses; release; removal; repair; repaired; repairing; repairs; report; reported; reports; require; resolution; response; result; retention; rotator; runs; ruptured; saphenofemoral; saphenous; scar; secondary; separate; services; sheath; short; simple; simply; site; size; skin; stage; state; stents; submission; suggested; superior; support; supracervical; surgeons; surgery; surgical; system; tags; tear; technique; tendon; tension; term; thrombotic; traumatic; treated; treatment; type; uncertain; undermining; underpaid; upper; urethroplasty; uterus; vaginal; vectors; vein; veins; versus; visual; weigh; weighing; weight; wound; zone

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