There are several tough coding issues ambulatory surgery centers face every day, whether they arise from incomplete documentation, coding updates or technical challenges with capturing the right information for procedures performed. In a webinar presented titled “Tough Coding Issues Facing ASCs,” National Medical Billing Services President Lisa Rock, Senior Vice President of Coding Tamara Wagner, and Senior Vice President of Coding Jessica Edmiston discussed these challenges and offered expertise on how to overcome them.
The first part of the presentation focused on addressing the quality of medical records. There are times when coding errors occur because operative reports are unclear or physicians don’t record all appropriate information necessary to capture the right codes.
“One of the most frustrating challenges right now is the template issue with electronic health records and electronic medical records systems,” says Ms. Rock. “Sometimes surgeons are using templates for procedures other than what they are doing because they aren’t available. In this case, free-texting doesn’t always work. You should always have a fall back in the old fashion dictation for scenarios such as this. You can’t code off of an operative report with blatant discrepancies and you can’t just guess.”
Other challenges that were addressed include:
When the information is consistently insufficient for accurate coding, coders can work on educating physicians about what type of detail is necessary to capture as much reimbursement as possible with every case. NMBS discusses the importance of knowing the differences between educating and leading the physicians with documentation concerns. Providing the physicians with carrier-specific policies and guidelines are examples of educational tools.
The second half of the presentation addressed common coding challenges specialty scenarios in areas of:
The first part of the presentation focused on addressing the quality of medical records. There are times when coding errors occur because operative reports are unclear or physicians don’t record all appropriate information necessary to capture the right codes.
“One of the most frustrating challenges right now is the template issue with electronic health records and electronic medical records systems,” says Ms. Rock. “Sometimes surgeons are using templates for procedures other than what they are doing because they aren’t available. In this case, free-texting doesn’t always work. You should always have a fall back in the old fashion dictation for scenarios such as this. You can’t code off of an operative report with blatant discrepancies and you can’t just guess.”
Other challenges that were addressed include:
- Inconsistencies within the operative report
- Variations between the procedure heading and actual description of the procedure
- Blanks in the medical records
When the information is consistently insufficient for accurate coding, coders can work on educating physicians about what type of detail is necessary to capture as much reimbursement as possible with every case. NMBS discusses the importance of knowing the differences between educating and leading the physicians with documentation concerns. Providing the physicians with carrier-specific policies and guidelines are examples of educational tools.
The second half of the presentation addressed common coding challenges specialty scenarios in areas of:
- Screening colonoscopies
- Bunionectomy
- Pain management
- Distal radial fracture
- FESS/turbinectomies
- Lesion excisions
- Pain block
- Conscious sedation
- Topaz ablation including wand
- Subtalar arthrodesis vs. arthroereisis
- Subacromial decompression
Access a PDF version of the National Medical Billing Association webinar here.
Access our webinar "Coding and Billing Updates that Could Impact Your Bottom Line Now and in the Future" to learn about the CY 2023 OPPS/ASC final rule, plus CPT coding changes and new codes added to the ASC Procedure List.
This post was first published May 4, 2012 and was updated July 29, 2020.