NAMAS Webinar Q&A: How to Audit Complex Surgeries: Step-by-Step Approach, 11/02/2021

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, How to Audit Complex Surgeries: Step-by-Step Approach, originally presented on November 2, 2021. These questions have been answered by the webinar presenter, Grant Huang, CPC, CPMA.

Question 1:
When an auditor comes to a family practice and audits charts and if they find injections/vaccines/I&D and or removals done in the office, does the auditor look to see if the patient signed a consent? If so, if its documented that the patient gave a verbal consent, does that suffice?
Answer 1:
Signed consent, whether on paper or stored in EHR/patient portal, is required for those types of minor procedures. A verbal consent from the patient, documented in the record and noted as such, and signed and dated by the provider, would be sufficient in most cases. From an auditor perspective, it can depend on what the client wants, but yes you should look for it unless instructed otherwise.

Question 2:
I do have a comment on the 3rd surgical case that you reviewed. Because the surgery was performed on the wrong body part, the procedure code needs modifier PA, at least for Medicare claims. PA- Surgical or other invasive procedure on wrong body part. The procedure was performed on another body structure instead of the appendix so, 44970 would be submitted with modifier PA and, then the unlisted code would be billed.
Answer 2:
Modifier PA is an informational modifier that is payer specific, so I would not use it unless there is explicit guidance from a payer to this effect. In our example the corrected claim and explanatory information accompanying it would convey the same information. It was not a Medicare patient in the example, but my position would be the same regardless whether it is commercial or Medicare.

Question 3:
We have about 20 ambulatory surgery centers in our division and as a result we encounter every kind of surgery that can be done as an outpatient.  Our only problem is that we do not have direct contact with the physicians that come to our centers to do their surgeries so have to rely on notes back and forth when questions arise regarding dictations. 
Answer 3:
I was not sure if this was a question or comment that you wanted an answer on, but I will just say broadly that dictated notes can sometimes be unreliable, especially dictated operative notes. I would suggest that some workflow protocol be developed whereby the most problematic dictation issues can be flagged and placed on bill hold until the performing surgeon can be contacted to resolve them. The compliance risk of guessing on operative coding is significant -- both in terms of overcoding and undercoding. The physicians signed those notes and they are liable for inaccurate or incomplete notes that result in inappropriate billing.

Question 4:
I currently work for a podiatry group.  If a physician makes multiple passes within the calcaneus is it considered 20902? I have researched this and I can't find anything that leads me to believe it is a 20902.  
Answer 4:
I think I'd need to see the documentation to really answer this, I don't quite understand the context of what the provider is doing -- was a bone graft obtained as a result of "multiple passes" being made? Is another procedure code being billed for which the descriptor includes the work of obtaining the graft (in which case 20902 is not separately billable)?

Question 5:
just this morning I had a coder ask me to review this case where she was considering adding 15002 to the 15275.  Here is the (main part of) documentation: Next the left foot and leg were prepped and draped in the usual aseptic fashion using Hibiclens. Next a sharp excisional debridement was performed to saucerized the wound edges on the posterior aspect of the left ankle ulceration. The wound was 2 cm x 3 cm with some hyper granulation tissue. At this time I took a 2 cm x 4 cm stravik skin substitute and sutured it with the ribs side against the wound using 3-0 Prolene. I then applied Mepitel once bleeding was controlled wrapped the ankle with 4 x 4's Kerlix and Ace. Patient tolerated above procedure and anesthesia well was transferred recovery in vital signs stable vascular status intact to left foot. We reviewed and decided to report 15275 for the skin substitute (2x4=8 sq cm).  We did not feel the documentation was enough to support the 15002-surgical preparation of the wound bed.  Wound bed preparation is much more than just a debridement and takes into account factors that impede wound healing. By creating a recipient wound bed that is well vascularized, free from infection and granular with even sloping margins, we can increase the chance of graft take and facilitate more reliable wound healing.  https://www.podiatrytoday.com/current-c ... reparation. And to make it more interesting, the surgeon told the coder that he didn’t think we can report both in the same session.  I have not heard of that, have you?  Do you agree with our coding on the above case? 
Answer 5:
I think this is a great example, I agree with your coding that the documentation is insufficient to bill the surgical prep. What I have seen is some doctors read "surgical preparation" and say "oh yeah I do that every time!" and then bill accordingly. The prep codes like 15002 require documentation showing that extensive work was required to prepare the area and gives specific examples in the descriptor ("by excision of open wounds, burn eschar, or scar, or incisional release of scar contracture"). To take the documentation you supplied, I would also be looking for some explanation of why a significant amount of extra work was needed to prepare the site. They say it was done "to saucerized the wound edges" which I take to mean they want it to better fit and align with the graft. That sort of work is simply part of applying the graft, it is not being done to fix the problem of having a significant, unworkable wound surface for grafting, like burn eschar, scar, infection, etc.

Question 6:
For case study #2, wasn't the note indicating a split thickness graft from the patient's body and not a skin substitute? Therefore it would be a split thickness autograft code e.g. 15100?
Answer 6:
Correct, this is an error where I pasted the wrong coding! My apologies. The correct example showed that 15002 and 15100 were reported. My explanation in the webinar regarding insufficient documentation to support surgical prep stands, and then the other remarks about wound measurements become moot as 15100 covers the first 100 sq cm and the sample note had measurements of 25-36 sq cm at most. Again I apologize and good catch!

Question 7:
Could the appendectomy case be billed with modifier 22?
Answer 7:
Potentially, but in my opinion the documentation does not quantify in any way the amount of extra time and/or resources needed. The documentation does a good job explaining what was done to address the location of the appendix but does not paint it in terms of additional difficulty and time/work/resources which is the modifier 22 standard. This is a good example of where the documentation would be enough for another clinician to say that extra work was significant, but not enough for a coder/auditor to say that from a medical/legal/compliance perspective.

Question 8:
Is there ever a situation whereby a separate procedure CPT is coded with another procedure and a modifier (59, x series) not applied?
Answer 8:
Only if there is no CCI bundling edit affecting them. The CCI edit pairs are what determines whether or not the modifier is needed.

Question 9:
My question is related to procedure detail. Specifically how much detail must be documented to support a procedure. For instance, if the physician documented that he performed a minimal partial acromioplasty is that sufficient detail to assign code 29826 or does the physician need to document reshape the acromion, or actually removing bone?
Answer 9:
It's a bit of a gray area where you don't have explicit language on this, but the CMS guidelines hold that an operative note should be sufficiently detailed such that another surgeon can recreate the procedure. So I think they absolutely would need to go into detail about what makes it "minimal."

Question 10:
Our provider usually does laparoscopic mobilization of the splenic flexure and then through an open approach ( makes an incision, releases the pneumoperitoneum, ports removed) she resects the intestine. How would you bill for the laparoscopic splenic flexure mobilization. Would you go with unlisted? Thank you.
Answer 10:
I would probably use modifier 22 over reporting an unlisted code as the work associated with the latter is quite high and not necessarily likelier to result in additional payment. The documentation should explain why (from a medical necessity standpoint) an open approach is being done with a laparoscopic mobilization, and quantify the extra work.

Question 11:
Slide 18- I missed conversion from diagnostic to performance of procedure. Why were these unbundled (59)?
Answer 11:
Slide 18 is the one with examples for modifier 25, so I am not sure what you mean by 59. It is the E/M code we are unbundling which requires -25 to be appended to the E/M code. Please feel free to follow up /w me if still unclear.

Question 12:
What was the name of that book?
Answer 12:
Surgical Anatomy and Technique by John E. Skandalaskis and others, 4th edition. I recommend the pocket reference edition (https://www.amazon.com/Surgical-Anatomy ... 1461485622).
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