Clarification of Equipment and Approach in Coding

by  Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
October 20th, 2014

When determining the type of approach taken in a surgical procedure, it is important to review not only the title of the report but also the body of the report to locate the method used.

Somewhere in the body of the report, and always preferably in the title, scope, endoscope, endoscopy or whatever the type of scope used should be stated. This information is vital to coders and insurance companies for claims coding and processing so if the equipment used isn’t clearly stated you may want to request your surgeon correct the report by adding an addendum.

The same is true for other methods of imaging such as fluoroscopy. If the report states that ‘fluoro' was used, that is sufficient. If the report shows the radiation exposure time but there is no mention of ‘fluoro' or fluoroscopy in the title or body of the report then it would be important to have the author of the report make an addendum to clarify this information.  
 
Besides correct coding and insurance reimbursement being affected by the clarification of equipment and approach, Medicare requires a PQRI code for many procedures performed with instrumentation such as fluoroscopy. These codes cannot be adequately reported unless the information is clearly stated in the medical report. Keep your providers on their toes with correct documentation habits to avoid any problems with reimbursement or audits in the future.
 
Special thanks to Genevieve Crane for the great coding tip suggestion. 

Clarification of Equipment and Approach in Coding. (2014, October 20). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/clarification-of-equipment-and-approach-in-coding-2318.html

© InnoviHealth Systems Inc

Article Tags  (click on a tag to see related articles)


Publish this Article on your Website, Blog or Newsletter

This article is available for publishing on websites, blogs, and newsletters. The article must be published in its entirety - all links must be active. If you would like to publish this article, please contact us and let us know where you will be publishing it. The easiest way to get the text of the article is to highlight and copy. Or use your browser's "View Source" option to capture the HTML formatted code.

If you would like a specific article written on a medical coding and billing topic, please Contact Us.


contact

innoviHealth Systems, Inc.
62 East 300 North
Spanish Fork, UT 84660
Phone: 801-770-4203 (9-5 Mountain)
Email:
free demo
request yours today
pricing
for any budget
sign IN
welcome back!

Thank you for choosing Find-A-Code, please Sign In to remove ads.