Clarification of Equipment and Approach in Coding

by  Aimee Wilcox, CPMA, CCS-P, CST, MA, MT
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

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