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Summer 2008

Additional Revenue Lies in the Accurate Documentation of the Procedure

Devona Slater
Auditing for Compliance and Education, Inc., Leawood, KS

In today’s environment, anesthesia providers may improve their reimbursement just by being more specific regarding the procedures that they perform. Many times in providing audits and reimbursement reviews, we find that the anesthesiologist does not give specific information for a coder to accurately code from the anesthesia record. This can result in a loss of revenue. An example is a general anesthetic given for which the procedure description was hydrocelectomy, inguinal hernia repair w/mesh. Based on the information on the anesthesia record, we would only be able to choose from the hydrocele repair (CPT 55040/00920 (3)) or the hernia repair (CPT 49505/00830 (4). A review of the surgeon’s record indicates the hydrocele involved the spermatic cord which would allow the coder to assign CPT code 55500/00860 (6). The accurate code assignment of this procedure would allow the group to bill an additional two units.

Another example is a thoraco-abdominal repair for a congenital diaphragmatic hernia. With this information, a coder would assign CPT code 39503 and cross walk it to ASA 00756 with seven base units. But in reading the surgeon’s report, the procedure was not done by a transabdominal approach but instead by a thoracotomy approach, which would allow the coder to use the alternate ASA code of 00540 which is a base unit value of twelve units. This means an additional five units that could be captured if the anesthesia provider had been more specific on the procedure description and noted the approach.

Another common mistake is that of an inguinal hernia repair. Anesthesia groups may be losing two units if the procedure was performed by the surgeon using laparoscopy. Again, simply documenting how the procedure was performed would allow the coder to easily assign the correct CPT code (49650/00840 Base 6) instead of the general code for inguinal hernia repair, CPT code 49505/00830 with a base of four.

A final example is one we see many times auditing and it is the description given as “cysto.” With this description the coder would only be allowed to assign CPT code 52000/00910 with base units of three. But if the surgeon manipulates the stone the coder would assign CPT code 52353/00918 with five base units. If in fact in reading the report the coder could determine that the calculus was in the kidney or upper 1/3 ureter, then the alternative code for 52352 or 52353, 00862 with seven base units, may be more appropriate to report. Again, the physician’s documentation is crucial in these instances to ensure we are getting the highest payment possible.

In today’s reimbursement environment one cannot afford to leave money on the table. It is important for anesthesiologists to realize that coding personnel are limited as to the description given or what is readily available. It is not possible for a coder to pull the surgeon’s dictation on every procedure. Physicians should be thorough and conscientious in describing the procedures that they perform so that coders can obtain the appropriate reimbursement for the services.