NAMAS Webinar Q&A: Surgical Auditing 10/01/19

Post here your questions regarding auditing ,coding, documentation, and compliance. Also, join in on the conversation- help your fellow auditors and compliance professionals in the industry.

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Below are the questions received during our recent webinar, Surgical Auditing, originally presented on October 1, 2019. These questions have been answered by the webinar presenter, Pam Vanderbilt, CPC, CPMA, CPPM, CPC-I, CEMC, CEMA, CEMA-O .

Question 1:
Do you have a credible resource that surgeons will not push back on the documentation of medical necessity for assists?
Answer 1:
I am not sure what MAC you are under, so I just picked one. The following link from Novitas includes clear guidance with the statement "Note: The operative note should clearly document the assistant surgeon's role during the operative session."
https://www.novitas-solutions.com/webce ... d=00144529

Question 2:
For a procedure like a spinal injection. what kind of description would be needed to support the injection. eg 64484
Answer 2:
I know the example is a knee, but it really identifies the level of documentation we are looking for to support any injection procedure. The report for a minor procedure should include:
1. Reason for procedure (to support medical necessity)
2. Specific anatomical site - i.e. tendon sheath, joint, which finger, vertebral level, etc.
3. Technique
4. Risk and Benefits – based on comorbidities of the patient
5. Details of the procedure
6. Outcome of the procedure

Due to the severity of the pain caused by the patient’s osteoarthritis, the decision was made to proceed with bilateral knee joint injections. After alcohol prep on each knee, taking lateral approach, posterior to the patella, a 25-gauge, 3.5-inch needle was advanced into each knee joint. Five mL of 0.25% Marcaine with 20 mg of Kenalog was injected into each side for a total of two injections. There were no complications and the patient tolerated the procedures well.

Question 3:
Is there written guidance from an authoritative source, (CMS, AMA, etc.) that states each co-surgeon must dictate their own operative note?
Answer 3:
“This modifier [-62] is used to report the services of two physicians related to a specific surgical procedure. If one surgeon, for example, performs the incision and exposes the area requiring surgery, and another surgeon then performs the surgery indicated in the code, both surgeons report the same procedure code with the -62 modifier appended. This indicates that only one total procedure listed in CPT was performed by these two surgeons. For example, CPT code 63064 Costovertebral approach with decompression of spinal cord or nerve root(s), (eg, herniated intervertebral disk), thoracic, single segment indicates that one procedure was performed. If one surgeon opens the area of the spine where the decompression will be performed, and another surgeon performs the decompression, then both surgeons would report 63064-62. Both physicians should document the level of involvement with this surgery in separate operative notes and include a copy of these operative notes when the service is reported to the third party payor. If one surgeon does not use the -62 modifier, the third party payor may assume that the physician reporting the procedure without the modifier performed the entire procedure - despite the second physician reporting the procedure with the modifier -62.”
American Medical Association. “Modifiers Used with Surgical Procedures”, CPT Assistant, Fall
1992, pages 15-22

Question 4:
How far back does guidance for NCCI edits go?
Answer 4:
"Carriers implemented NCCI Procedure-to-Procedure(PTP) edits within their claim processing systems for dates of service on or after January 1, 1996 and began implementing  Medically Unlikely (MUE) edits on January 1, 2007."
https://www.cms.gov/Medicare/Coding/Nat ... index.html
THe archives can be found at https://www.cms.gov/Medicare/Coding/Nat ... chive.html

Question 5:
NAMAS used to have a surgery audit form under the audit tools on the website. It is no longer there. Will this ever be posted again in the future?
Answer 5:
NAMAS is working to update this audit tool. Watch for future notifications.

Question 6:
What do you mean.. when you say the. MN, for the AS?
Answer 6:
I am not sure what MAC you are under, so I just picked one. The following link from Novitas includes clear guidance with the statement "Note: The operative note should clearly document the assistant surgeon's role during the operative session."
https://www.novitas-solutions.com/webce ... d=00144529

Question 7:
When it comes to the assistant can you talk about what you should expect to see to justify why they have an assistant?
Answer 7:
At a minimum, the work done by the assistant and the complexity of the case to require the need for the assistant on cases that require support of medical necessity to support the assistant.
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