decisionhealth Newsletters, Coder Pink Sheets - 2008 Issue 3 (March)
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Article Overview
This article presents coding questions and answers on when a laparotomy performed in connection with a hernia repair should be reported as part of the repair, and how reviewing diagnostic procedure results can affect medical decision-making for E/M services. It is useful for coders, auditors, and billing staff looking for general guidance on procedure reporting and data review concepts without substituting for the full premium discussion.
Why This Topic Matters
The article helps readers recognize how surgical intent, bundled services, and diagnostic test review can influence code selection and evaluation and management leveling. It is relevant to anyone trying to align documentation and billing with the actual service performed.
Article Sections
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Laparotomy included in hernia repair
Discusses a question about reporting a laparotomy performed in the course of a hernia repair and the relationship between the documented intent of the surgery and procedure reporting.
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Review of diagnostic procedure results and MDM
Addresses how reviewing results from a procedure performed by another provider may factor into medical decision-making for E/M services.
What You Will Learn
- How the article frames procedure reporting when multiple operative steps occur during one surgical encounter
- How surgical intent and the performed service are discussed in relation to coding
- How review of diagnostic results may relate to E/M medical decision-making
- How the article distinguishes separately billable services from information used in E/M leveling
Who Should Read This
- Medical coders
- Coding auditors
- Billing staff
- Revenue cycle professionals
- Physician documentation specialists
Codes Discussed
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