06/22/17 – Complete documentation = accurate coding

Question: What are some key items we should be documenting on our records to make sure SupportMed is able to choose the most specific and highest base anesthesia code?

Answer:

The key to correct reporting is to have accurate and complete documentation.  A complete description of the surgical procedure as well as all procedures performed should be documented.

Below are 5 items that the coder’s at SupportMed find to be missing the most from documentation:

  1. Hardware or multiple levels for spinal procedures – if hardware was used or if the procedure was performed on multiple levels (3 vertebral bodies with 2 interspaces), the base unit can bump up by 5 units, 00630 with 8 units vs. 00670 with 13 units.

 

  1. One lung ventilation – if a procedure is performed with one lung ventilation, the base unit increases by 3. One lung ventilation can be documented by simply writing OLV on the record.

 

  1. Testing for cardioverter-defibrillators – If the defibrillator functions are tested, the code bumps up by 3 units. Please make sure to document that testing was done in addition to placing the defibrillator.

 

  1. D&C’s with hysteroscopy – if the surgeon performs just a D&C for vaginal bleeding, the code is 00940 at 3 base units. If a hysteroscopy was used in addition, the procedure bumps up to code 00952 with 4 base units.

 

  1. Upper vs. lower abdomen – if the procedure was done on the upper abdomen, the ASA code is 00790 at 7 base units, if it was done on the lower abdomen, the ASA code is 00840 at 6 base units. Please make sure to document upper vs. lower abdomen.

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