Episode 9: Common Misunderstandings of Surgical Coding

Episode Transcript

CJ: Welcome, everybody, to another episode of Compliance Conversations. I’m CJ Wolf, Healthicity's Senior Compliance Executive, and today you were talking to Christopher Chandler, who is a Senior Consultant with Intermountain Healthcare’s medical group in the professional coding in reimbursements department. This is a department I use to work in; it’s where I first got started after I left medicine and they were looking for somebody dumb enough to try to teach doctors about Medicare compliance. And I said, "I don’t know anything about that," so I guess I was dumb enough, and I loved it. So, I'm really glad to be talking to you today, Christopher, and we’re going to be talking a little bit about general surgery coding and compliance issues. Christopher, before we get started, I’m going to have you introduce yourself a little bit and tell us what you do.

Christopher: Yes, thank you, I’m happy to be here. I also came into this job with no medical experience but It’s been a wonderful opportunity to learn a lot. So, I am the general surgery, trauma surgery and breast surgery, coding consultant for Intermountain Healthcare on the professional side, so that entails me meeting with physicians, practice managers, staff, charge entry coders and consulting them and helping them with their coding and their documentation tips and keeping them updated as the guidelines change, as well.

CJ: Yeah, that’s great. And for those of you don't know Ontermountain Healthcare is a large health system in the intermountain west, mainly Utah and Idaho, I believe those are the only….

Christopher: We have one hospital in Idaho and I think a total of twenty-two hospitals, so . . .

CJ: Yeah, a very large system, well known for quality services and keeping prices low and quality of care high.

Christopher: It’s a great healthcare system.

CJ: Yeah, it is wonderful. How many physicians do you guys work with?

Christopher: So, there are about fifteen hundred, I think, between twelve hundred to fifteen hundred physicians that we work.

CJ: So yeah, a lot of doctors. I wanted to kind of provide a little bit of that background so you guys know that these senior consultants that work with Intermountain Healthcare are the real experts, I mean, they are on the front lines dealing with doctors' concerns and questions and all sorts of things. So, I'm excited to be able to talk a little bit about the general surgery today.

Christopher: Thank you. I am too.

CJ: So, let’s just kinda get started with, maybe, I'll just start with a general question, what are some of the common misunderstandings of surgical coating, in general?

Christopher: So, I feel like a lot of the misunderstandings of surgical coding comes when people don't understand the coding system, they don't understand how it works, how there are global surgical packages or the ICD coding works with the CPT coding, or there's multiple procedure overlap. Things like that. There are ways that the surgery codes will fit perfectly into what the physician is doing, and then there are ways that it doesn't fit perfectly, but when you understand the system, you know how to code it in a way that will accurately reflect what the physician is doing, even if that one code doesn't perfectly describe what the physician did, that surgery that they did.

CJ: Yeah, the codes are written in a way to capture most of how a certain procedure is done, right? But there may be some variances in what the doctor actually did or plans to do. Can you elaborate on that part a little bit?

Christopher: Yes, there are things called inherent services that are just considered inclusive within the surgery code, but they aren't in the details of the description of the code, But then there are also, getting to your point, there are also things where the physician will modify or change the surgery in some way, and that may completely change the code, or may just alter it in a way where you can throw a modifier on there that will tell the payer, “This is still the same inherent code but has been changed a little bit, and here's how it’s been changed.”

CJ: Yeah, and do the physicians do the coding or are they advising coders to pick the codes?

Christopher: So, it’s kind of a mix here with my general surgeons at Intermountain Healthcare. Some of them will do the coding themselves, others will write the surgeries down on a form. Now we’re switching to an EHR, and they are a little bit more involved with the coding now. So, they do select most of their coding themselves; they may have help with the ICD coding.

CJ: So, when you’re educating them, are you kind of sharing PowerPoints, or some sort of media where you share the description of the code? I imagine some of the docs understandable them a little better than others.

Christopher: Sure.

CJ: So how do you get them to understand what is included in that general, like you mentioned in inherent services, how do you help them understand what’s already included?

Christopher: So, my favorite thing to do is, I will take some of their documentation that they've already done and I'll sit down with them and I’ll say, “Look you reported on this one a cholecystectomy with an E&M visit and a cholangiogram, but you missed this because of this.” Or maybe they coded something extra that they shouldn’t, and I can show them right there in the documentation. Yes, you did this, but it was already included in here, and I can find a source for them, whether it's from Medicare, the NCCI policy manual, the AAPC, whatever it may be, or maybe even their surgical society, the American College of Surgeons, where I can say, "Here is where they are saying it's already included in the reimbursement." And that’s where a lot of physicians get really frustrated. They don't see these inherent services. They think, “I'm not getting paid for this because there isn't a code that accurately reflects it." But they are getting paid for it, they are getting reimbursed for it, they just don’t see it in the description. Now, some physicians may argue that the dollar amount doesn’t equate to that, but that’s a whole different story, but the principles of it still apply that they are getting reimbursed for it.

CJ: Yeah, I don’t know if you’ve used this analogy, but when I first started working for Intermountain years ago I worked with a director, Ellen North.

Christopher: Yes, I did too.

CJ: We were talking one day and she said, “It’s kind of like a value meal." And so, we were talking about going to a fast food restaurant, and it was a great analogy to try to help both coders and doctors understand that, look, when you order a burger, fries and drinks you pay a price. And what comes included in that price is if you ask for some napkins, or you ask for a straw, or a packet of ketchup--that’s included, you're not paying more. And they’ve kind of worked that in as an average. Some of us like eight packages of ketchup, and some of us have sloppy kids in the car so you have lots of napkins. And they’ve kind of worked that into an average price, but if you order a apple pie on top of the value meal, that's when you get another code, so to speak, and another payment. Is that a good way to kind of explain that to folks?

Christopher: You know what, it's a great way to explain it. In fact, I use the same analogy. I just spoke that HEALTHCON for the AAPC, and I used that analogy there. And I made sure to let them know that I did my research and went a lot of McDonalds to make sure I understood this process correctly. But it is the same the same type of a thing, and if you think of it from a payor perspective, me as a customer, I don’t want to pay for each one individually, which is going to costs $6.00, when the value meal will cost $5.30. So, if you think about it in that way, and you think about if rom a payor standpoint, Medicare or private insurance, they don't want to do the same thing. They don't want to pay you twice for only doing something once, and that's what happens a lot of times when a physician tries to use a code for every little thing they're doing. They end up telling the payor, "I did this twice," unintentionally telling the payor they did it twice. But that’s what they're saying when in all reality, they only did it the one time.

CJ: I’m a little rusty on my general surgery coding so maybe help me out here, but is an example of that, let’s say you’re going to go in and you mentioned a cholecystectomy before. I know a lot of these are done laparoscopically now, but let’s say you’re going to do an open procedure, there is a separate CPT code I think for an laparotomy, which is just going into the abdomen, but if you’re doing that as a part of or a step to get into something deeper and further, that laparotomy is considered included. Is that a good example?

Christopher: It is, that’s a great example. In fact, if you break it down to the RVU’s of it--so every code has an RVU, Relative Value Unit, and physicians are paid a certain dollar amount per RVU--the exploratory laparotomy code, I think it's 49000, that has 12.54 RVU, and the open cholecystectomy code has 15 or 16 RVU. So, what they're basically saying is that cholecystectomy alone was not worth 16 RVU, it’s worth that 12.54 RVU from the exploratory laparotomy and then the actual removal of the gallbladder is the extra 4 or 5 RVU, because everything you're doing in the exploratory laparotomy, a physician would do when they did an open cholecystectomy anyway. So, they know that, so they’ve bundled it in, so now physician doesn't have to build two codes instead they just have to build one. So, they made it easier for the physician in that sense, but when the system is misunderstood it doesn’t appear that way.

CJ: Yeah, because if I’m a doc. I’m going to say, "Well I did the exploratory lap and I did cholecystectomy. So look there are two codes; I want both." Does that the 49000 still say a separate procedure?

Christopher: Yes, it does. Yes.

CJ: You knowc I had doctors say, “Yeah look, it even says separate procedure, I did it as a separate procedure”, but that’s a misunderstood concept in coding, right?

Christopher: Absolutely, in both CPT manual and the NCCI manual focus a lot on separate procedure codes, and codes that are classified as separate procedure codes do not mean you can report it separately. What it means is it’s a much smaller portion of a larger procedure. An example of the open exploratory laparotomy with the cholecystectomy, they know that you're always going to do an open exploratory laparotomy in order to do a cholecystectomy. But there are times when you will only do an open exploratory laparotomy, and so in those times when you only do that, that’s when you report that 49000 code for the open exploratory laparotomy. The way that they state it in the CPT manual is they say if it’s done by itself or it's unrelated to the other procedures, that’s when you can report one of these separate procedure codes. And then the NCCI manual takes it further for general surgery and says, basically, a separate procedure code in the abdomen that is performed at the same time as another procedure is probably never separately reportable. It’s probably going to be bundled in with that larger code, and you’ll be reimbursed for it there.

CJ: Yeah, so you’ve mentioned the NCCI manual and I know what that is but maybe tell some of our listeners who might not know. Explain what that is.

Christopher: Yeah, absolutely. So, the NCCI Manual is the National Correct Coding Initiative from Medicare. It’s a big book of guidelines and rules, but basically it's there to help us better understand this surgical coding system and the coding system, in general. It's there to help us up be able to identify what these inherent services are and understand when this code should not be reported with this code or when they can be reported together. Things like that. Some people don’t like it, I find it a very valuable tool to have correct coding and to reduce denials and things like that.

CJ: Yeah, I always use to tell docs, "You may not like what Medicare is paying you, but at least they are somewhat transparent in their saying this ABC and D are all included in F. So at least they are saying that, and they are saying that F pays this." Like you mentioned earlier, you can argue that it’s not enough money, and that’s a different forum to kind of argue that. The coding rules are what they are, and you can try to attack that in a different way, but from a compliance officer’s perspective, which is where I’m coming from, you don’t want to attack that feeling of feeling under-reimbursed by coding a lot of other things by boosting your reimbursement, because that’s where you get into compliance trouble.

Christopher: And that’s where you get noticed too, and they come after you.

CJ: Yeah, exactly. When I’ve spoken at many conferences where I talk about how the government is using data analytics to find those people who have abhorrent billing patterns, and those billing patterns are what kind of what clue them off, so to speak.

Christopher: Yes.

CJ: So, let’s talk more about that surgical package, then. What’s included in one? Tell me some surgical speak of what are the types of things that are included in that?

Christopher: Yeah, absolutely. So, one of the main things, and we’ve mentioned it before, are the separate procedure codes, so we don’t need to rehash that. All the pre-op work and all the post-op work is going to be considered inclusive. Now I’ll say "typical post-op work," because for a lot of private payors they will pay for complications separately. Medicare, on the other hand, will not pay for the evaluation and management of surgical complications in the post-op period. They’ve assumed that surgical complications are pretty common, whether the physician is just the most amazing physician in the world, or just a brand new one that is just working things out, but they happen, and so they assume you will probably have to do evaluation management of some surgical complications. So they don’t pay separately for it. They will pay if it results in going back to the OR and they’ll pay for the surgery, but they won’t pay for that E&M. So, all the pre-op work and post-op work is considered inclusive. And another thing that they will focus on a lot is anesthesia. The NCCI policy manual focuses on this a lot as well. If the physician performing the surgery also provides and administers the anesthesia, the administration of that anesthesia is not separately-reportable.

CJ: Ahhh, so if you had a separate anesthesiologist or APRN they would be able to bill their anesthesia services separately?

Christopher: They would. This is only the case if the physician providing the surgery is also the one administering the anesthesia.

CJ: So, you mentioned pre-op. What are some of the pre-op services that are considered included?

Christopher: So you get that typical pre-op history and physical that happens before every surgery. Whether it’s a minor procedure or major procedure, you have a pre-op history and physical that happens. And sometimes it’s just bundled in with that initial E&M, but with these major procedures they usually happen the same day or the day before the surgery. And that’s why a lot of times, not a lot of times, always, the global package begins the day before the surgery.

CJ: Yeah, it’s like a negative one, day negative one.

Christopher: Yeah, because they want to make sure they take into consideration that there is a pre-op H&P. Now, the exception to that would be when the decision for surgery happens that day of or day before, and that’s when you can use modifier 57 to indicate to the payor this is not the pre-op H&P, this is the first time I’m seeing the patient about this. And you see this a lot in the ER. They’ll have someone come in for right lower quadrant pain, and they do a CT scan, they do a history of physical, and the assessment is acute appendicitis. It looks like it’s about to perforate, let’s get in there and take care of it. In that situation that E&M in the emergency room should be reported. It’s not the typical pre-op H&P. So in those situations, it’s really good for a physical to have good documentation, letting them know that they presented to the ER, that this is the first time they are seeing them about it. This is where the decision for surgery happens because Medicare has said once that decision for surgery occurs, anything associated with that, any evaluation management service associated with that surgery between the time the decision for surgery happens and the time the surgery actually occurs, is considered inclusive and not separately reportable. So, it’s important for physicians really document that well.

CJ: So, Christopher, let me ask you, kind of if I were to think like a doc for a moment and try to get around some of these global surgical packages, you mentioned that pre-op HNP kind of the day of,or the day before. What if I started doing them two days before?

Christopher: Still considered inclusive because once that decision for surgery is made, anything related to that surgery until the surgery actually occurs is considered pre-op and considered bundled in with the global package. A physician may try to get a little sneaky or a coder may try to get a little sneaky and try to do that, but Medicare has thought ahead and said, "No, anything associated with a surgery that happens in that time."

CJ: But it wouldn’t necessary, or correct me if I’m wrong, it wouldn’t necessary hit an edit if you reported an E&M two days before the surgery?

Christopher: No, it wouldn’t.

CJ: So that’s kind of why I bring it up. You might think oh, because in my history of working in compliance a lot of folks would be like “If it doesn’t hit an edit than I’m okay.” Well that’s necessarily true, and it’s kind of what I believe is that, just because you get around edits doesn’t mean that it’s appropriate, and if it’s a true pre-op H&P and it’s done before that’s still considered part of the global and you shouldn’t report it separately.

Christopher: Correct, and that’s the same mentality of just because there is a code for it doesn’t mean you can actually code for it. Just because it hits an edit doesn’t mean it’s correct. Edits are not perfect; there are not edits for everything. The guidelines, you know, maybe Medicare will catch it when it actually goes to them and they will deny it but I don’t know if they will or not.

CJ: So how about post-op, some common things, like changing dressings, taking out sutures, staples?

Christopher: All of that is going to be considered inclusive. Any sort of minor evaluation and management stuff is going to be inclusive. That typical post-op care is the way the CPT manual describes it. The NCCI policy manual then goes on, and Medicare goes on to say, complications, as well, we’re not going to cover, as well, unless it results in going back to the OR.

CJ: What about if you have different doctors doing different pieces? So, let’s say I’m on vacation and I have an emergency appendectomy or something and then I go back home and that doctor does most of the follow-up. How is that dealt with?

Christopher: So, there are modifiers that they can use to accurately reflect that. There is modifier for just the procedure only. So, the physician performs only the procedure but not any of the post-op work, so the physician would report that appendectomy code with that modifier, indicating that "I’m not doing the post-op work. I shouldn’t get paid for the post-op work." Then when the other physician sees you later and does all the post-op work, they can bill that same code, but with the post-op modifier on there. And then it won’t hit any problems with Medicare, they can clearly see this was initiated this procedure. This did that. That’s in a perfect world. It doesn’t happen that way a lot of times. A lot of the times the first physician will not even think about it and just report the code as normal and then the second physician gets really frustrated saying well now I’m supposed to do all this work and I’m not going to get paid for it.

CJ: Yeah. So, let me ask you, the global periods can vary depending on a major or minor procedure. Can you comment on the length of time for each of those?

Christopher: Yeah, absolutely. So, there’s three global periods for these codes. There’s a 0-day global period, a 10-day global period, and a 90-day global period, and so depending on the complexity and intensity of the procedure and what type of code it is will depend on which global period you have.

CJ: Gotcha. We’re kind of wrapping up here a little bit so let me go back, just briefly, to the beginning you mentioned something about ICD-10 codes. What do you see as an issue with ICD-10 coding in the context of general surgery coding?

Christopher: I think one of the most important things is specificity. A lot of the times physicians will not choose the most specific diagnosis code that there is. But the important thing to remember about diagnosis coding is it is explaining to the payor why that surgery was justified. So, if they payer doesn’t feel it was justified because your ICD-10 coding wasn’t good enough, then you may be in trouble or out of luck or they may not pay you as much or whatever it may be, but that is something that I’ve seen a lot. Their documentation is specific enough, but their ICD-10 codes are not, so it’s not reflecting all around and it may cause some trouble later on.

CJ: And this is gonna age me a little bit, but that was an issue with ICD-9, as well.

Christopher: Yes, it was.

CJ: I know that ICD-10 can have even more granularity and specificity than ICD-9 but the concept was the same. So, what do you do with docs, or is it a coder issue if the coders are picking the ICD-10 codes, what's your approach?

Christopher: Depending on if it’s the coder or the physician . . . the physicians, I think, have gotten it down really well that their documentation needs to be that specific. Is it acute? Is it chronic? Is it the left side, the right side? Things like that. And then if they are selecting the diagnosis code, in the new EHR that we’ve implemented here at Intermountain Healthcare has got a really wonderful feature where you can select all these specific things and it will spit out the code that accurately reflects that for them. So that really helps the physicians out in that sense.

CJ: Great. Well Christopher I think we could probably talk all day, and maybe we’ll just have you come back as another guest, but I really appreciate your expertise and your time today. Any parting thoughts or comments to the coders and compliance folks that might not live and breathe coding all day? We have a lot of compliance officers listening that need to know concepts. Any last-minute thoughts?

Christopher: I think that there are plenty of resources out there that people can read and better understand. You don’t need to be a coding expert or even a medical expert to understand these. But it is important to better understand that system as a whole. And there are so many avenues of the system it can become very complex. But having a better understanding of how it works helps physicians and coders and practices be more compliant with their coding and their documentation.

CJ: Yeah, and I think, again, thinking back on my days here at Intermountain, we regularly read the NCCI manual. I know you’ve read it and explained it a little bit. It’s published, it’s out there publicly on the internet, and I think quarterly there are updates, so you need to watch for the updates, not just for the actual numeric edits, but also there may be narrative changes in the manual portion of it as well.

Christopher: Yes, there are, and all have to do is just google Medicare NCCI Policy Manual and it will take you straight to the link. You can download it. We download a new one every year and make sure for each consultant in their specialty make sure we that we have found the new updates and then inform our physicians of those updates and then inform our physicians of those updates.

CJ: And that’s kind of why I bring it up in closing here. If you’re a compliance officer and you don’t necessarily want to become a coding expert, at least you can ask your coding folks, "Are you looking at the NCCI manual on a regular basis, making sure you’re accounting for changes, and then getting that information out to your doctors and coders?"

Christopher: And the changes in the CPT manual each year, as well. They are highlighted in green, so they are easy to find each year.

CJ: Well, Christopher, thank you so much for your time.

Christopher: Thank you.

CJ: And thank you all for listening to another episode of Compliance Conversations. Until next time, this is CJ Wolf signing off.